Reminiscence therapy has become increasingly popular in dementia over the last two decades. Many care homes or dementia groups offer reminiscence therapy as part of their activities and ‘non-pharmacological’ treatments. Despite the wide use of this form of therapy, the actual benefit for people with dementia is not as clear as one would think.
So, what is the scientific evidence that reminiscence therapy works and which symptoms in dementia can it potentially alleviate?
Reminiscence is defined as ‘a story told about a past event remembered by a narrator’. Reminiscence therapy allows, therefore, people to revisit events in their past, which might alleviate some of their current issues or symptoms. Three types of reminiscence therapy are commonly recognised:
- Simple reminiscence – describes activities which usually involves the recall and sharing of selected memories or stories. The memories can be either shared among a group or specific to the individual.
- Life review – also referred to as life story work, which is usually a more structured review of an individual’s life story with their personal memories.
- Life therapy work – describes activities more targeted towards people with depression. The goal of this type of reminiscence is to go specifically through negative memories and re-evaluate them in a more positive light.
In essence, reminiscence therapies allow more or less structured reviews of the past to improve people’s outlook on life. Such ‘thinking back to the past’ has been shown to have beneficial effects for older people who have depression. Not only does it reduce the level of depressive symptoms but also increases the quality of life of older, healthy people.
What about people with dementia?
The idea that reminiscence therapy could also be of benefit to people with dementia originates on the observation that depressive symptoms can be also common in dementia – in particular in the early disease stages. The other interesting aspect of using this type of therapy in dementia is that reminiscence focuses mostly on memories long ago. Most of us will be aware that those remote memories remain intact in people with Alzheimer’s disease for longer than more recent memories. This phenomenon is often reported by families of people with dementia, as that they are living in the past’ since their remote memories are fairly good for older memories, while they have little or no recollection for very recent events. The actual explanation for this ‘living in the past’ is by itself interesting and we will explore this in a future post. The key for reminiscence therapy is that it allows people with dementia to focus on memories they can recall very well and not dwell on the more recent memories they cannot remember. It allows them, therefore, to ‘play to their strength’, which should have a positive impact on their well-being and outlook.
Overall, reminiscence therapy seems therefore ideal for people with dementia, as it can alleviate potential depressive symptoms, while at the same time playing to the strength of having better memories for remote events, improving the overall quality of life. Reminiscence therapy has, therefore, not surprisingly been adopted by many dementia centres and groups.
What’s not to like?
The issue is that reminiscence therapy has been widely rolled out across dementia services and groups, with very little systematic evidence so far, although very promising anecdotal results.
It makes me sometimes wary when techniques or therapies for which there is little scientific evidence are rapidly deployed. On the one hand, I can understand that people are desperate to offer a technique or therapy to people with dementia, as so few are available to them. On the other hand, it can create somewhat false hope that these techniques or therapies work for most people, despite there only being anecdotal evidence and not systematic evidence of whether they work. I strongly believe that only if there is systematic evidence in the form of scientific evidence, such new techniques or therapies should be recommended to anyone. If such systematic evidence is not available then clinicians or healthcare professionals should carefully evaluated for each individual whether this new technique or therapy might be suitable to them.
Only now we are in a position when the scientific evidence is becoming firmer as more studies and trials are conducted using reminiscence therapy to check if it makes a difference to people with dementia on a systematic level.
A recent systematic review addressed this issue by reviewing the existing scientific evidence as to what beneficial – or adverse – effects reminiscence therapy has for people with dementia. The authors identified a total of 22 studies, including 1972 participants. All participants had dementia, ranging from mild to moderate disease stages, with studies being conducted either in community settings (day centres) or care homes. The authors were particularly interested as to whether reminiscence therapy improved the overall quality of life in people with dementia. This was their main interest and therefore referred to as a ‘primary outcome measure’.
They also had several ‘secondary outcome measures’ which they wanted to explore. For example, did reminiscence therapy improve the cognition, communication, behaviour or mood of people with dementia? Finally, they checked whether reminiscence therapy had also an effect on the carers of people with dementia, such as improving the carers mood, quality of life or caring relationship to the person with dementia.
What did they find?
The most surprising finding was that across all the studies the authors did not find a positive effect of reminiscence therapy for improved well-being or quality of life in people with dementia. However, there was an interesting split, in that care home based reminiscence therapy had a small benefit for people with dementia, whereas reminiscence therapy in the community did not. It is unclear why this difference in setting emerged. One could speculate that the therapy was more systematically administered in more formal settings, such as care homes, whereas it might have been more varied or less structured in community settings. This clearly needs to be investigated further in the future.
How about the other, ‘secondary’ outcomes from the analysis?
The secondary outcomes, in fact, showed some small beneficial effects of reminiscence therapy for people with dementia. For example, there was a small improvement in cognition after reminiscence therapy directly at the end of the intervention. It is an interesting finding, as it potentially suggests that triggering older – more intact – memories might benefit cognition in general by actively engaging in such memory retrieval. Similarly, there was a small beneficial effect for improved communication of people with dementia after the reminiscence therapy. Interestingly, in particular, group sessions of reminiscence therapy had a more positive effect on communication than individual sessions, highlighting that encouraging people to speak about their past might aide their overall communication.
Despite these small beneficial effects, none of the other secondary outcomes from the analysis should any positive effects. Specifically, reminiscence therapy did not seem to improve behavioural changes such as agitation and irritability, or overall functioning. The most surprising finding was, however, that reminiscence therapy did not improve mood, and in particular depressive symptoms in people with dementia. Let’s remember that one of the original purposes of reminiscence therapy was the reduction of depression, which has shown consistent, positive results in older people. Not so for people with dementia, which might highlight that reminiscence therapy has little benefit for treating depressive symptoms in dementia, despite it being its original purpose. Again, this controversial finding needs to be investigated further in the future.
The other surprising finding was that there was no beneficial effect on the carers mood, well-being or quality of life, even if they took part in the reminiscence therapy. There was even an adverse effect in some studies for carers, as the reminiscence on happier times, impacted their mood negatively. It seems, it was for some carers a reminder of the good times they had together, which, considering their current situation, made them sad. This is a potentially important finding, which if verified in future studies, raises the question as to whether reminiscence therapy should include the carers or not, as it might adversely affect their mood.
In summary, it comes a bit of a surprise – at least to me – that reminiscence therapy which is so widely used in dementia care shows on a systematic level limited benefit to people with dementia. The small benefits so far identified in studies seem to be most consistent for improved cognition and communication following reminiscence therapy, with no measurable benefits for well-being, quality of life, behaviour or mood.
There was also no benefit for carers of people with dementia, although some studies showed that the reminiscence on the ‘good, old days’ had a negative effect on carers. Likely reminding them of what they had lost.
Where does this leave reminiscence therapy for dementia?
It is an interesting question, which is not easy to answer, as there emerges now a split between the positive anecdotal results but little systematic benefits for reminiscence therapy. It brings us back to my previous point, that based on these findings, reminiscence therapy should be carefully considered for each individual by clinicians and healthcare professionals but there is little evidence to suggest that it works for everyone – for now.
For the future, the finding that there was a split between the care home and community settings for the benefit of reminiscence therapy, suggests that it might be worth reviewing what was done differently in the care homes. Since people with dementia benefitted more from reminiscence therapy in care home settings, the factors which influenced this would be important review as it would be a way forward for more people with dementia to benefit from this type of therapy.
In the end, the other positive aspects of reminiscence therapy in improving communication and cognition in dementia might still make it worthwhile. Although, based on the scientific evidence involvement of carers in reminiscence therapy should be carefully considered as it can potentially affect them adversely.