Plan B Paper

Running head: REMINISCENCE THERAPY AND DEMENTIA

The Effects of Reminiscence Therapy on Communication Interactions

in a Person with Dementia

Megan L. Feidt

January 2015

A Plan B Research Project Presented to

The Graduate Faculty of the University of Minnesota Duluth

Department of Communication Sciences and Disorders

In Partial Fulfillment of the

Requirements for the Degree Masters of Arts in

Communication Sciences and Disorders

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REMINISCENCE THERAPY AND DEMENTIA

Abstract

The purpose of this study was to determine the effectiveness of Reminiscence Therapy (RT) on

communicative interactions between a single subject with dementia and their communication

partner. RT is a direct, discussion-based, psychosocial intervention, that involves the discussion

of past activities, events, and experiences with tangible items from the past, such as photographs,

household, or other familiar items (i.e., conversation pieces). The question of whether or not RT

improves communication interactions between a person with dementia and their communication

partner is the basis of this research. A single-subject experimental ABAB withdrawal design was

used to observe changes in the subject’s communication. Measurements included the amount of

the subjects’ communicative turns, and linguistic measures of mean length of utterances (MLU),

and type token ratios (TTR) during RT sessions, as compared to baseline measures with no

treatment. Results indicated that the highest amount of communicative turns occurred during

treatment sessions with RT as opposed to baseline. There was no meaningful pattern of

differences in results between the treatment sessions with RT and baseline sessions for the

linguistic measures of MLU and TTR. Subjectively, treatment sessions with RT produced higher

levels of social engagement, sense of self, and improved mood and as compared to baseline

sessions.

Keywords: dementia, reminiscence therapy, psychosocial intervention

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Introduction

Dementia is an acquired neurological syndrome that results from disease of the brain. It is

characterized by a progressive degeneration in higher cortical functions, including memory and

other cognitive domains such as, language, judgment, abstract thinking, and executive

functioning. This multi-faceted cognitive impairment interferes with social and occupational

(i.e., functional) impairments as well. Meaning, individuals affected by dementia have difficulty

engaging in everyday activities of daily living, as well as comprehending and expressing

linguistic information with the same level of independence earlier in life (American Speech-

Language-Hearing Association, n.d.; Brookshire, 2007; Ripich & Horner, 2004).

There are four subtypes of neurodegenerative dementias including, Alzheimer’s

Dementia (AD), Lewy Body Dementia, Vascular Dementia, and Frontotemporal Lobar Dementia

(Ripich & Horner, 2004). AD is the most common cause of neurodegenerative dementia (ASHA

n.d.; Kim et al., 2006) and accounts for approximately 60-70% of individuals with dementia

(Ripich & Horner, 2004; Plassman et al., 2007). In 2002, the prevalence of dementia among

individuals 71 years and older was 13.9%, about 3.4 million individuals in the United States. The

relative values for AD were 9.7%, about 2.4 million individuals in the United States (Plassman et

al., 2006). In 2014, prevalence data stated that as many as 5.2 million individuals in the United

States have AD; this number is expected to continue to grow, rising to 13.2 million by 2050

(Hebert et al., 2003). The projected rise in cases of dementia is directly linked to the aging of the

current population, which is quickly becoming the fastest growing clinical population for speech-

language pathologists (SLPs) (Ripich & Horner, 2004). Given these large numbers, no known

medical cure, and the progressive nature of the disease, it is critical to help these individuals

remain as active in life events for as long as possible helping to give meaning to their lives

(Clark, 1995).

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Assessing and providing effective communication intervention to individuals with

dementia is quickly becoming a part of SLP’s caseloads. According to the ASHA (2005), SLPs

have a primary role in the screening, assessment, diagnosis, and treatment of dementia related

cognitive-communication disorders. When providing treatment to this clinical population it is

important for SLPs to implement a holistic and humanistic model, rather than the commonly

used traditional medical model (Hopper, 2005; Clark, 1995). The humanistic and holistic model

shifts focus from restoring and/or remediating function to behavioral management, which is

aimed to maintain function and quality of life in the growing number of individuals affected by

dementia (Clark, 1995). SLPs play a vital role in dementia care by implementing interventions

with unique expertise in cognition and communication (Kim et al., 2006).

SLPs can provide treatment through direct or indirect therapeutic approaches. The two

approaches to treatment have different focuses. Direct treatment approaches maximize function

by working directly with the individual who has dementia, whereas indirect treatment focuses on

maximizing function by managing external factors, such as their environment, or interactions

with caregivers (Clark, 1995; Kim et al., 2006). The progressive nature of dementia causes

deterioration in communicative effectiveness to occur in stages. Therefore, some therapeutic

approaches are chosen over others depending on the individuals’ communication and cognitive

strengths and weaknesses, as well as disease progression (Clark, 1995). Direct interventions

include, but are not limited to reality orientation, spaced retrieval training, external cues and

memory aids, Montessori-based programs, validation therapy, and reminiscence therapy. Indirect

interventions include, but are not limited to environmental manipulation, and caregiver education

programs. These treatment approaches are not mutually exclusive.

It is imperative that individuals with dementia maintain function and quality of life as

long as possible despite their progressive cognitive decline. However, research investigating the

use of therapies aimed to improve quality of life and weaken the symptoms of dementia has only

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been explored in recent years (Hopper et al., 2013). The need for a paradigm shift was outlined

by Clark (1995), which stated the need for SLPs and other health care professionals to shift their

treatment from the traditional medical model (i.e., restoring/remediating dysfunction) to a

holistic and humanistic model (i.e., functional maintenance). The therapies researched in recent

years include direct interventions, such as cognitive training, physical exercise, music therapy,

and reminiscence therapy, as well as indirect interventions, such as caregiver education, which

were all recently reviewed by Olazaran and colleagues (2010). These humanistic and holistic

therapeutic-like interventions aim towards enhancing communicative interactions, engagement,

and quality of life, and differ from the traditional medical model. However, a need for effective,

research-based interventions that differ from the traditional medical model still exists. This

research study aims to contribute to the recently surfacing research on the effectiveness of

interventions aimed towards improving the quality of life, communicative interactions and

engagement in this adult population.

According to Woods, Spector, Jones, Orrell, and Davies (2005), reminiscence therapy

(RT), is a direct, psychosocial approach to intervention that is often used in dementia care. The

classic implementation of RT involves the discussion of past activities, events, and experiences

with tangible items from the past, such as photographs, household, or other familiar items (i.e.,

conversation pieces) in group or individual settings. However, Subramaniam and Woods (2012)

state that as many as two to eight varieties of RT are described in the literature today. Due to the

number of different types and functions of reminiscence work, a key distinction must be made

between its narrative and informative function, and its integrative function.

Reminiscence work that focuses on sharing stories and memories from the past with

others is considered narrative and informative, whereas reminiscence work that focuses on the

individual making sense of their own life story is considered integrative function, which is

known as Life Review (Subramaniam and Woods, 2012). Typically, integrative reminiscence is

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conducted individually, but narrative and informative reminiscence can be done in one-to-one or

in a group setting. Narrative and informative reminiscence aims to trigger more general

reminiscence of a broad range of stories and memories based on chosen themes or topics

(Subramaniam and Woods, 2012). For example, a reminiscence therapy session centered on

“Catholic school days” may include photos of things associated with Catholic school, and

include tangible items such as chalk, erasers, or pencils. These memory triggers can be general or

specific in nature.

Originally, psychotherapists used reminiscence as the basis of a therapeutic approach to

improve psychological and social functioning for older adults. Kim et al. (2006) reported several

studies that found positive effects of RT with cognitively intact older adults including, positive

changes in self-esteem and affect, increased life satisfaction, decreased depression, increased

communication skills, spontaneity, and laughter. Reminiscence has a cognitive basis as well. It

appears that individuals with dementia retain the ability to recall events from their childhood, but

not from earlier the same day (Woods et al., 2005). Because of their ability to preserve remote

memories better than recent memories, reminiscence therapy is theorized to capitalize on a

person’s cognitive strengths rather than their impaired cognitive abilities. Therefore, it is

hypothesized that discussion of previous life events would result in enhanced communication

reactions (Woods et al., 2005; Kim et al., 2006). Other goals of RT described by Woods et al.

(2005) include, to increase sense of self, to increase sense of belonging through an engaging

activity given the company of others, to improve mood and well-being, to improve general

cognition and behavior, to stimulate memories, and/or increase the individualization of care.

To date, research into the effectiveness reminiscence therapy for people with dementia

has been slow to emerge. Evidence-base for the effectiveness of RT rests largely on descriptive

and observational studies. In recent years, randomized control trials have begun to surface;

however, these studies may be considered exploratory in nature (Subramaniam and Woods,

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2012; Woods et al., 2005). A systematic review was undertaken in 2012 by Subramaniam and

Woods and examined the impact of individual RT for people with dementia. The review

included five studies by Lai et al. (2004), Politis et al. (2004), Haight et al. (2006), Haslam et al.

(2010), and Morgan & Woods (2010). These studies incorporated comparisons of different types

of interventions under a variety of conditions (i.e., general reminiscence, reminiscence with the

use of kits, other social activities, specific reminiscence, life review/life story book, and

“treatment-as-usual”). Significant results identified include, improvements in depression,

communication, mood, cognition, autobiographical memory performance, well being, and

quality of life. Three of the five studies (Lai et al., 2004; Haight et al., 2006; Morgan & Woods,

2012) with significant results incorporated the use of specific reminiscence with life review/life

story books. Despite these findings, reminiscence therapy continues to be the subject of criticism

from researchers who identify the lack of evidence to support its use because of the low quality

and variation in outcomes, which is perhaps related to the diverse forms of RT used in studies

(Woods et al., 2005). Therefore, evidence from studies involving randomized control trials to

form conclusions about the efficacy of RT for people with dementia remains insufficient.

The current study aimed to expand evidence on the effectiveness of RT with a narrative

and informative function for a person with dementia. Specifically, through the investigation of its

effects on communication as measured by communicative turn taking, type-token ratio, and

mean-length utterance.

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Methods

Setting

Research was conducted in dementia unit in a long-term care facility in Duluth,

Minnesota. All of the residents in this unit are at varying stages of disease progression and have a

diagnosis of dementia, or suspected dementia. Research was primarily conducted in the subject’s

room; however, if the subject expressed the desire to walk around within the unit during

sessions, the investigator engaged the subject in RT while doing so.

Subjects

Several long-term care facilities were contacted via phone and were informed of the

current study. After a long-term care facility expressed interest to be involved in this study, their

activities director provided information concerning which resident they thought would gain the

most from participating in this study. Information about the study and requests for consent were

given to the legal guardian/s of the resident as well as the activities director of the long-term care

facility; he/she completed the consent process with the resident’s legal guardian/s to ensure the

subject’s anonymity until consent was obtained. Following the consent process, a phone

interview was completed with the resident’s legal guardian/s to gather insight on the resident’s

social history. This allowed the investigator to choose and discuss relevant topics of conversation

with the resident by individualizing the RT sessions. To make certain the subject was open to

participating in communication encounters with the investigator and minimize the possibility of

undue influence, assent was obtained prior to the initiation of each session. The subject chosen

for this study was a 99-year-old, female, with vascular dementia, as indicated by her medical

records.

Research Design

A single-subject experimental ABAB withdrawal design was used to observe changes in

the subject’s communication during treatment sessions, as compared to baseline measures. Data

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were collected during initial baseline with no treatment (A), initiation of treatment (B),

withdrawal of treatment (A), and initiation of treatment again (B). Each baseline (A) included 5

sessions that were 10-15 minutes in duration. Treatment sessions (B) also included 5 sessions

that were 10-15 minutes in duration. To facilitate a natural flow of conversation, the investigator

and subject were seated or walking within close proximity of each other during sessions.

Treatment sessions (B) were conducted during late November through December and included

discussions of Christmas, Catholic schooldays, history of the resident’s hometown,

marriage/church, family, and hobbies, as these were revealed as topics of interest from the

previously gathered social history information.

Treatment and Baselines

Baseline sessions (A) consisted of spontaneous conversation between the investigator and

the subject. The investigator initiated conversation with the subject by asking the following

open-ended question, “how are you doing today?” during baseline sessions. After conversation

was initiated, the investigator followed the subject’s lead for the remaining conversational topics.

Treatment sessions (B) utilized RT techniques. In this treatment, the subject was encouraged to

converse with the investigator given stimulating conversational topics (i.e., past activities,

events, and experiences with another person and/or group of people) and tangible items of

interest, such as photographs or household items (i.e., conversational pieces), that were based on

the social history that was collected. Conversational pieces were shown to the subject and placed

on the table or in the subject’s hands to view and touch during conversation. The content

accuracy of the subject’s communication turns was not of interest for the purpose of this study;

therefore, inaccurate statements were counted as communication turns and conversation

continued.

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Data Collection

Each of the sessions was audio recorded using an iPad® 4 and was placed within close

proximity of the investigator and subject during all baseline and treatment sessions. After

sessions were completed, the investigator transcribed the recorded sessions. The recordings were

viewed on the password protected iPad® located on the University of Minnesota Duluth campus

in a private office. The transcription process involved recording the investigator and subject’s

conversation verbatim.

Transcribing the conversation verbatim allowed the investigator to measure the number

communicative turns, and linguistic measures of type-token ratio, and mean length of utterance

per session. Communicative turns included vocal communicative turns that consisted of at least

one word (e.g., “that’s nice” or “oh”) or continuer/filler (e.g., “mmhmm,” or “uh-huh”); any

reflexive and/or physiological vocalizations (e.g., cough, clearing throat) were not counted as a

communicative turn. Type token ratio (TTR) measured the variety of vocabulary words used by

the subject within a conversational speech sample. It allowed the investigator to examine the

relationship between the total number of different words used, and the total number of words

used (Rutherford, 2000). The procedures used to measure TTR followed Rutherford’s (2000)

guidelines, which divided the number of different words by the total number of words. Mean

length of utterance (MLU) measured the average number of morphemes that the subject

produced in an utterance within a conversational speech sample (Shipley & McAfee, 2009). For

the purposes of this study, MLU was calculated using the guidelines outlined by Shipley &

McAfee (2009) for counting the number of morphemes per utterance. Unlike communication

turns, MLU did not count continuers or fillers (e.g., um, oh, you know).

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Results

Type Token Ratio

The relationship between the total number of different words used, and the total number

of words used by the subject (i.e., TTR) was calculated for all baseline sessions (A) and

treatment sessions (B). Generally, the results of TTR calculation revealed a trend of a larger

variety of vocabulary words used by the subject during basline sessions (A) as compared to

treatment sessions with RT. Signifying that there was no meaningful pattern to suggest that RT

increased the variety of words in the subject’s conversational speech samples. Instead it suggests

a decline in the variety of words used during RT. This trend is especially evident in the

withdrawal of treatment sessions (A) and initiation of treatment a second time (B) sessions. A

visual display of TTR values for each session are shown in Figure 1.

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Mean Length of Utterance

The mean length of utterance (MLU) was calculated for all baseline sessions (A) and

treatment sessions (B) and measured the average number of morphemes that the subject

produced in an utterance within each session. Due to the purposes of this study, MLU did not

count continuers or fillers (e.g., um, oh, you know). A slight increase in MLU is observed during

the initiation of treatment (First Phase B) and initiation of treatment a second time (Second Phase

B) sessions when compared to withdrawal of treatment (Second Phase B). However, the results

of MLU were similar to results of TTR as there was no significant pattern to suggest that RT

increased the length of the subject’s utterances as compared to baseline sessions (A). A visual

display of MLU values for each session are shown in Figure 2.

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Communicative Turns

The number of communicative turns was calculated for all baseline sessions (A) and

treatment sessions (B). For the purposes of this study, a vocal turn in conversation that consisted

of at least one word (e.g., “that’s nice” or “oh”) or continuer/filler (e.g., “mmhmm,” or “uh-huh”)

was considered a communicative turn; reflexive and/or physiological vocalizations (e.g., cough,

clearing throat) were not counted as a communicative turn. With the exception of baseline

session 2 (Phase A) and treatment session 6 (Phase B), the results of the total communicative

turns for each session revealed a trend of higher number of communicative turns in treatment

sessions as compared to baseline sessions. . However, the subject exhibited a lower number of

communicative turns during both of the second phase baseline and treatment sessions.

A visual display of the number of communicative turns for each session are shown in Figure 3.

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Discussion

Results from this investigation provided information regarding the effects of RT on

communication interactions in a person with dementia. Results indicate that this direct,

discussion-based, psychosocial intervention is effective in increasing certain elements of

communication in persons with dementia. Outcomes from this study indicate that when a

resident is engaged in RT with a communication partner, an increase in communication

interactions occurs, specifically the number of communicative turns. This finding suggests RT is

more effective at improving elements of communication that support social engagement, sense of

self, and mood in persons with dementia, rather than increasing linguistic elements of

communication. Although the results for linguistic measures (i.e., TTR, MLU) did not result in

meaningful patterns to suggest an improvement in communication interactions, the improvement

in communication engagement, sense of self, and mood are consistent with findings of previous

studies by Woods et al., 2005 and Kim et al., 2006, along with studies included in Subramaniam

and Woods’ 2012 systematic review.

When examining Figure 1, it is clear that TTR exhibited inconsistent changes between

the baseline sessions (First Phase A) and treatment sessions (First Phase B). However, a

considerable increase of TTR is evident between the withdrawal of treatment sessions (Second

Phase A) and initiation of treatment a second time (Second Phase B) sessions. Given that RT

involves conversation surrounding a previously chosen topic or theme of conversation and the

incorporation of tangible items from the past, persons with dementia may find themselves

discussing the same subject matter; ultimately, leading to less variety in vocabulary words used.

Rather, spontaneous conversation may elicit a wider range of vocabulary words due to

environmental stimuli and/or randomly occurring thoughts. This suggests that TTR values may

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be somewhat higher when conversation is spontaneous because any topic or environmental

stimuli is available for discussion.

The results from Figure 2 show that the measure of MLU also exhibited some

inconsistent changes between the baseline sessions (Both Phases), and treatment sessions (Both

Phases). However, a slight increase in MLU is observed during the initiation of treatment (First

Phase B) and initiation of treatment a second time (Second Phase B) sessions when compared to

withdrawal of treatment (Second Phase A). RT involves the discussion of past activities, events,

experiences with tangible items from the past, such as photographs, household, or other familiar

items. Often, this discussion based intervention elicits stories from a person with dementia’s past,

as compared to spontaneous conversation that commonly elicits randomly occurring thoughts or

general commentary. This is a plausible explanation for the slight increase exhibited in MLU

during treatment sessions (B) in comparison to lower MLU measurements during baseline

sessions (particularly, Second Phase A).

Figure 3 demonstrates that there is a notable increase in the number of communicative

turn between baseline sessions (A) and treatment sessions (B), with the exception of Session 2

(Phase A) and Session 6 (Phase B). During session 2 (Phase A) the subject requested to walk

around the unit, rather than stay in her room. This resulted in a disproportionately higher level of

commentary on environmental stimuli. Session 6 (Phase B) sessions was considered omissible

due to the subject’s attitude towards the chosen conversational topic–Christmas, as it generated

unhappy memories of being poor and living through the great depression. Also, both of the

second phase baseline and treatment sessions showed a generally lower number of

communicative turns by the subject; this could potentially be due to the subject’s decreased

attention and/or interest in the conversational topic; these sessions were also shorter in duration

(i.e., 10 minutes, rather than 15 minutes). During RT, the subject appeared to be more emotional

and socially invested in the conversation and showed signs of improved mood and confidence in

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her conversational skills. This finding suggests that RT enhances certain elements of

communication, specifically social engagement, sense of self, and mood.

While this study is of small scale, and results must be interpreted with caution, this result

may warrant further exploration of the effects of RT on social engagement, well being, and

quality of life in persons with dementia. Although there was no meaningful pattern of

improvement in linguistic measures (i.e., MLU, TTR), differences in social engagement, sense of

self, and mood reflect the positive impact RT may have on certain elements of communication

with this clinical population. Further investigation into this area would be helpful towards not

only incorporating a more humanistic and holistic model of intervention, but also contribute to

the research on the effectiveness of interventions aimed towards improving the quality of life,

communicative interactions and engagement in this adult population.

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Acknowledgements

The completion of this Plan B research project would not have been possible without the

guidance of some special individuals. I wish to thank my Plan B Advisor, Mark Mizuko, Ph.D.,

and Plan B research committee members, Jolene Hyppa-Martin Ph.D., and Bob Lloyd, Ph.D. for

their time spent offering feedback and guidance with this project. This project has helped me

understand and appreciate what an SLP can do when interacting with this clinical population.

I also wish to thank all of the great people at Benedictine Health Center (BHC),

especially Stacie Oakland. The completion of this research project would not have been possible

without your help. The dedication you have to serving the residents at BHC is truly inspiring.

Thank you for contributing to my education and experience working with this population. Most

importantly, I wish to thank the family who were willing to endure the consent process, and who

provided permission for their loved one to participate in this research. Finally, to the resident, I

am eternally grateful for everything you have taught me.

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