Feature ArticleThe effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults in long-term care: A systematic review
Introduction
In many countries, long-term care (LTC) for older adults who have poor physical and/or mental health and functional disabilities is a common part of the aged care system. For example, a broad range of recent estimates of older adults in long-term care are: Australia 5.3%1; Malaysia, 0.08%2; United States of America, 3.9%3; United Kingdom, 4.1%4; Germany, 3.2%.5 Although these percentages indicate only a small proportion of the population, the level of disability and the type of care required is significant and this will become a larger issue over the coming decades as the world population of older adults increases disproportionally to other age groups.6
The move into LTC can be very stressful for an older adult and debilitating feelings of loneliness, anxiety and depression is a significant feature.7 These feelings can last up to four years after admission to LTC.8 Other problems identified by older adults when relocating to LTC include difficulty in establishing meaningful interpersonal relationships with other residents and staff,9, 10, 11 loss of identity and purpose in life,12 sadness and boredom13 and lack of social support.14
The prevalence rate of loneliness in LTC older adults has been reported as high as 56%15; prevalence rate for anxiety as 14%15 and prevalence rate for depression as 71.8%.16 Loneliness can be defined as the loss of valued interpersonal relationships or inability to establish satisfying relationships.17 Loneliness is a risk factor for physical and psychological health deficiencies such as dementia,18 depression,19, 20 anxiety20 and cardiovascular diseases.18 Anxiety can be defined as “an anxiety and worry about several real-life problems, occurring for at least six months”.21 Anxiety is often an unrecognized comorbidity of depression.22 Depression is defined as depressed mood or loss of interest in activities of daily living for more than two weeks that can be diagnosed based on several symptoms such as depressed mood, decline in interest and pleasure and weight loss or weight gain.21 Both depression and anxiety are undertreated in older adults.23, 24, 25, 26 The symptoms of anxiety and depression are difficult to diagnose due to coexistence with physical problems and the misbelief that these conditions are a part of the normal aging process.24 Undertreated depression and anxiety can lead to low quality of life, other more serious diseases and a shorter life span.27 Suicide is also a risk for older adults with depression.28
Several approaches such as pharmacological and non-pharmacological strategies can be used to treat or prevent loneliness, anxiety and depression. Loneliness is not a condition amenable to drug treatment but can be treated through psychosocial measures such as group therapy. Pharmacological treatment such as psychotropic drugs is usually the first option to treat depression and anxiety. Common psychotropic drugs in use are antidepressants, anxiolytics, hypnotics and antipsychotics. The excessive or moderate use of psychotropic drugs can lead to insomnia, depression, falls, hyponatremia, fracture and epilepsy.29, 30 Due to the adverse effects of psychotropic drugs, it is prudent to use non-pharmacological treatments such as health education, counseling and psychotherapies as the first option.
Reminiscence therapy is one type of psychotherapy that could alleviate feelings of loneliness, anxiety and depression among older adults. Reminiscence by definition is a method or technique to recall past memories.31 Therapy itself can be defined as the branch of medicine that deals with different methods of treatment and healing in the cure of disease.32 Reminiscence therapy can be defined as uses the recall of past events, feelings and thoughts to facilitate pleasure, better quality of life and better adjustment to present circumstances.33 Reminiscence therapy can be structured or unstructured, and conducted in a group or individual34 setting. Reminiscence is known as reminiscence therapy when it involves communication between two or more individuals and the achievement of certain goals based on individuals needs. Reminiscence therapy is different from simple reminiscence whereby certain elements should be considered, such as: where the therapy takes place, the aims of the therapy, the theory that may underpin the therapy, the types of participants involved, and the qualifications of facilitators.35 It is stated that there were important elements that differentiate reminiscence from other therapies.36 In reminiscence therapy, the participants are free to discuss their life stories and they can focus on both pleasant and sad memories.36 At the same time, participants can learn something from their past problems to shape their present life.37 The value of reminiscence therapy above and beyond other therapies is that it may help older people gain their personal value38 and self-identity39 by recalling past memories. Given today's challenges in LTC, this therapy is valuable because it can be conducted during normal activities of daily life in LTC, such as during mealtime and walking around the facility LTC.38 Furthermore, staff in LTC reported that reminiscence therapy enhanced their interaction with residents, increased work satisfaction, and developed their understanding of the residents.39
Three types of reminiscence therapy are identified in the literature, simple reminiscence, life review and life review therapy.31, 35 Simple reminiscence is defined as unstructured spontaneous reminiscence with the goals to increase social well-being of older people.31, 35 In comparison to simple reminiscence, life review more structured and focused on both positive and negative life events. Life review therapy, is an advanced type of reminiscence therapy, which is a more formal and in-depth intervention.40 Life review therapy is conducted when dealing with a particular problem34 and can be psychotherapeutic for people who are severely depressed or anxious.31, 35
Eight functions of reminiscence therapy were identified.41 Briefly, these were 1) Identity – appreciating oneself; 2) Problem Solving – recognizing one's own strengths in dealing with problems; 3) Death Preparation – facilitating acceptance of death; 4) Teach/Inform – sharing life stories with intent to teach; 5) Conversation – developing ways of communication with other people; 6) Bitterness Revival – revisiting memories of difficult life events; 7) Boredom Reduction – reminiscing to relieve feelings of boredom; and 8) Intimacy Maintenance – remembering significant people. It was found that the eight functions of reminiscence therapy41 could be grouped according to three higher order dimensions linked to well-being: positive self-functions, negative self-functions, and pro-social functions.42 Positive self-functions referred to preserving or developing self-awareness and included reminiscence for Identity, Problem Solving, and Death Preparation. Negative self-functions related to regrets about the past and rumination and included Bitterness Revival, Boredom Reduction and Intimacy Maintenance. Pro-social functions of reminiscence fostered relatedness with others such as Conversation and Teach/Inform. These functions of reminiscence therapy have relevance to older adults with depression, loneliness and anxiety. For example, Bitterness Revival, Boredom Reduction and Intimacy Maintenance functions may enhance well-being for older adults with depression. Problem Solving, Death Preparation, and Teach/Inform may be appropriate for older adults with anxiety. Identity, Problem Solving, Teach/Inform, Conversation, Boredom Reduction, and Intimacy Maintenance functions may be applicable to older adults who are lonely.
There are different types of reminiscence therapy such as transmissive reminiscence, integrative reminiscence, instrumental reminiscence and spiritual reminiscence. Transmissive reminiscence is defined as sharing past life events from one generation to the next generation.43 Integrative reminiscence therapy focuses on reviewing past events irrespective of whether these were negative or positive experiences. The aim of integrative reminiscence is to develop positive self-esteem and links between past and current memories, as well as energizing negative memories.44 Instrumental reminiscence therapy examines how past events have been resolved to enhance self-esteem.45 Finally, spiritual reminiscence therapy is defined as life review that involves people trying to find the meaning of their life and their future hopes.46
Some therapists prefer to use individual reminiscence therapy47, 48 but there is evidence to support the effectiveness of group reminiscence therapy. Group reminiscence therapy usually comprises six to ten participants in each therapy session to enhance group dynamics, whereas individual reminiscence therapy is conducted on a one to one basis.49 When comparing group reminiscence therapy to individual reminiscence therapy use in LTC, at least three authors preferred group reminiscence therapy since it encouraged social contact between the residents, enhanced communication skills, and established new relationships.11, 40, 50 Furthermore, a systematic review of reminiscence therapy for the treatment of depression established that the social role function of group reminiscence therapy was the defining factor that made it more effective than individual reminiscence therapy.51 From a financial appraisal, group reminiscence therapy was more cost-effective than individual reminiscence therapy.40
The present systematic review expands previous work51 by including loneliness and anxiety as well as depression. It was found that loneliness could be a risk factor for anxiety20 as well as depression.19Anxiety is a common comorbid condition with depression; nevertheless many individuals may have anxiety without depression.52 To differentiate between anxiety and depression is a challenging task due to the similarity in the presentation of symptoms of depression and anxiety.23, 25 Therefore, it is worthwhile to look at these three outcomes together as they are interrelated conditions often experienced by residents of LTC.7, 53 The use of group reminiscence therapy in LTC is also of interest. The research question guiding this review is: ‘what is the effect of group reminiscence therapy on reducing feelings of loneliness, anxiety and depression, in older people diagnosed with symptoms of loneliness, anxiety and depression residing in long-term care settings?’54
Section snippets
Methods
The Joanna Briggs Institute's (JBI) method for a comprehensive systematic review was used to guide the study.55
Results
A summary of study characteristics is presented in Table 2. Only one study examining an outcome of loneliness was found.57 Two studies examining anxiety58, 59 and eight studies examining depression34, 43, 57, 58, 59, 60, 61, 62 were identified. Three studies measured more than one outcome.57, 58, 59 Of the eight studies, three studies were from the United States of America (USA),34, 43, 58 three studies were from Taiwan,57, 61, 62 one study from the United Kingdom (UK),59 and one study from
Quality of the studies
The assessment of methodological quality revealed that three of the eight studies met the minimum score of five out of the ten criteria. No study included the important step of concealment of allocation to treatment groups by the allocator – i.e., criteria 3. However the included studies were quasi-experimental studies. The studies fulfilled similar criteria in the methodological quality assessment checklist. For example, all eight studies had comparable groups, identical treatment except for
Recommendations
Only a few studies identified the benefits of group reminiscence therapy for loneliness, anxiety and depression in older adults in LTC. Moreover, all studies in this review were quantitative studies. Thus, diverse research designs were needed for a clearer understanding of group reminiscence therapy as a whole. That is, qualitative studies and mixed-method studies might provide different views of the effectiveness of group reminiscence therapy. Qualitative work might be beneficial to provide a
Conclusion
The majority of group reminiscence therapy studies reviewed were quasi-experimental and included small participant samples, therefore there are no conclusive findings to be made. Notwithstanding the lack of empirical evidence, as there are no reported adverse events to reminiscence therapy, and it can be practically implemented in long-term care settings, it should certainly be considered a worthwhile treatment.
Acknowledgments
The first author would like to acknowledge the Malaysian Ministry of Education and International Islamic University Malaysia for the scholarship support.
References (74)
- et al.
Relocation stress syndrome: a comprehensive plan for long-term care admissions: the relocation stress syndrome diagnosis helps nurses identify patients at risk
Geriatr Nurs
(1995) - et al.
Lessons learned from 5 women as they transition into assisted living
Geriatr Nurs
(2008) - et al.
Loneliness and social support among nursing home residents without cognitive impairment: a questionnaire survey
Int J Nurs Stud
(2011) - et al.
The management of loneliness in aged care residents: an important therapeutic target for gerontological nursing
Geriatr Nurs
(2011) - et al.
The prevalence of anxiety in older adults: methodological issues and a review of the literature
J Affect Disord
(2008) - et al.
Screening for adolescent depression: a comparison of depression scales
J Am Acad Child Adolesc Psychiatry
(1991) - et al.
Development and validation of a geriatric depression screening scale: a preliminary report
J Psychiatr Res
(1982) - et al.
Celebrating fifty years of research and applications in reminiscence and life review: state of the art and new directions
J Aging Stud
(2014) Residential Aged Care in Australia 2010-11: A Statistical Overview
(2012)Social Statistics Bulletin Malaysia 2012
(2012)
The National Nursing Home Survey: 2004 Overview
Care of Elderly UK Market Survey 2012/13
Services for Older People in Europe: Facts and Figures About Long Term Care Services in Europe
Ageing and Life Course: Interesting Facts About Ageing
Nursing home residents' perceptions of relocation
J Clin Nurs
Perceptions of Hong Kong Chinese elders on adjustment to residential care
J Interprof Care
Voices of elders: culture and person factors of residents admitted to long-term care facilities
J Transcult Nurs
The role of context and the interpersonal experience of loneliness among older people in a residential care facility
Glob Health Action
Older peoples experiences of relocation to long-term care
Nurs Older People
Predictors of self-assessed health, anxiety, and depressive symptoms in nursing Home residents at week 1 postrelocation
J Aging Health
Determinants of depression and insomnia among institutionalized elderly people in Malaysia
Asian J Psychiatr
Loneliness and the health of older people
Int J Geriatr Psychiatry
Loneliness, health and depression in older males
Aging Ment Health
A mixed-methods approach to understanding loneliness and depression in older adults
J Gerontol B Psychol Sci Soc Sci
Diagnostic and Statistical Manual of Mental Disorders: DSM-5
Comorbidity of depression and anxiety in the elderly
Curr Psychiatry Rep
Anxiety, depression, and comorbid anxiety and depression: risk factors and outcome over two years
Int Psychogeriatr
Depression and the elder person: the enigma of misconceptions, stigma and treatment
J Ment Health Couns
Assessment of anxiety in older adults: a systematic review of commonly used measures
Aging Ment Health
A multiplicity of approaches to characterize geriatric depression and its outcomes
Curr Opin Psychiatry
Treatments for late life depression in primary care—a systematic review
Fam Pract
The relationship between depression and loneliness among homebound older persons: does spirituality moderate this relationship?
J Relig Spiritual Soc Work
Improving geriatric mental health nursing care: making a case for going beyond psychotropic medications
Int J Ment Health Nurs
Antidepressant use and risk of adverse outcomes in older people: population based cohort study
Br Med J
Reminiscence and mental health: a review of recent progress in theory, research and interventions
Ageing Soc
Concise Medical Dictionary
Nursing Intervention Classification (NIC)
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Funding: IIUM/202/C/1/1/5377.