RESEARCH ARTICLE
Randomized controlled trial of a six-week spiritual reminiscence intervention on hope, life satisfaction, and spiritual well-being in elderly with mild and moderate dementia Li-Fen Wu1 and Malcolm Koo2,3 1
Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan 3 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Correspondence to: M. Koo, PhD, E-mail: [email protected] 2
Objective: Reminiscence therapy has been reported to improve the well-being in patients with dementia. However, few studies have examined the effects of spiritual reminiscence, which emphasizes on reconnecting and enhancing the meaning of one’s own experience, on patients with dementia. Therefore, this study aimed to investigate the effects of spiritual reminiscence on hope, life satisfaction, and spiritual well-being in elderly Taiwanese with mild or moderate dementia. Methods: A randomized controlled trial was conducted on 103 patients with mild or moderate dementia recruited from a medical center in central Taiwan. The patients were randomly assigned to either a 6-week spiritual reminiscence group (n = 53) or control group (n = 50). The Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being were administered before and after the 6-week period. Results: The interaction terms between group and time for the three outcome measures were found to be significant (P < 0.001), indicating that the changes over time in them were different between the intervention and control groups. Conclusions: Findings of this randomized controlled trial showed that hope, life satisfaction, and spiritual well-being of elderly patients with mild or moderate dementia could significantly be improved with a 6-week spiritual reminiscence intervention. Copyright # 2015 John Wiley & Sons, Ltd. Key words: spiritual; reminiscence therapy; complementary medicine; dementia; elderly History: Received 19 November 2014; Accepted 15 April 2015; Published online 11 May 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4300
Introduction Caring of patients with dementia is a critical public health issues in many parts of the world, particularly in those with aging populations (World Health Organization, 2012). It has been estimated that over 81 million people will be affected by dementia globally by 2040 (Ferri et al., 2005). The worldwide societal cost of dementia is estimated to be US$422 billion (Wimo et al., 2010). Results from a meta-analysis of Diagnostic and Statistical Manual of Mental Disorders IV diagnosed dementia indicated that the pooled prevalence Copyright # 2015 John Wiley & Sons, Ltd.
of dementia in people aged 60 years and over in mainland China, Hong Kong, and Taiwan is 4.6% (95% confidence interval: 3.4%, 5.8%) (Wu et al., 2013). Dementia is characterized by chronic and nonreversible deterioration in memory, loss of executive function, and changes in personality. It implies a long period of suffering for the patient and severe emotional and financial burden on the patient’s family and caregivers. In addition, mortality rates also increase as a result of various infectious complications associated with being bedridden at the end-stage of the disease. Many clinical trials have evaluated the Int J Geriatr Psychiatry 2016; 31: 120–127
Spiritual reminiscence and dementia
efficacy of various medications with mixed results (Olsen et al., 2005; Hansen et al., 2007). Generally, acetylcholinesterase inhibitors and memantine appeared to be marginally beneficial on the cognitive, behavioral, and psychological symptoms of dementia in some patients. The effectiveness of antipsychotic medications, benzodiazepines, antidepressants, and mood stabilizers is also unclear (Butler and Radhakrishnan, 2012). Besides pharmacological treatment, psychological interventions such as cognitive behavioral therapy along with usual care have been examined and found to be effective in reducing symptoms of depression and clinician-rated anxiety for people with dementia and therefore have the potential to improve patient well-being (Orgeta et al., 2014). Other nonpharmacologcal interventions such as music therapy (Vasionytė and Madison, 2013), aromatherapy (Forrester et al., 2014), massage (Viggo Hansen et al., 2006), and exercise programs (Forbes et al., 2013) have also been evaluated. However, because of the variation in the results between trials and methodological concerns, additional research is still required to demonstrate whether these interventions can improve the cognition, behavior, depression, and mortality in patients with dementia. Another psychological intervention in dementia care that has gained attention in recent years is the reminiscence therapy (Woods et al., 2005). According to Bluck and Levine (1998), reminiscence can be defined as “the volitional or non-volitional act or process of recollecting memories of one’s self in the past. It may involve the recall of particular or generic episodes that may or may not have been previously forgotten and that are accompanied by the sense that the remembered episodes are veridical accounts of the original experiences. This recollection from autobiographical memory may be private or shared with others.” Reminiscence therapy is defined by the American Psychological Association as “the use of life histories—written, oral, or both—to improve psychological well-being.” (Vandenbos, 2006). An early theory put forward for reminiscence therapy was the “disengagement theory” (Cumming and Henry, 1961), in which successful aging is viewed as a process of withdrawal from personal relationships and society. Under the “ego-integrity theory,” an individual who achieves ego-integrity through looking back on their life and accomplishments does not fear the uncertainty associated with death (Erikson, 1994). Butler (1963) extended the ego-integrity theory to the “continuity theory,” in which reminiscence is viewed as a way for an individual to adapt to changes that Copyright # 2015 John Wiley & Sons, Ltd.
121
occur in different stages of his or her life. Change is linked to the individual’s perceived past and therefore producing continuity in inner psychological characteristics. In addition, reminiscence group therapy may provide an opportunity for interaction and stimulation of a positive self-attitude among group members (Lin et al., 2003). In reminiscence therapy, patients are encouraged to talk about the past to bring past experiences into consciousness. However, reminiscence is more than simply recalling the past. It is reflexive process in which one can introspectively define or redefine oneself (Parker, 1995). Previous studies have used various indicators to measure the effects of reminiscence therapy on cognition, psychology, behavior, and health of elderly individuals. For example, Rosenberg’s SelfEsteem Scale, Health Perception Scale, Geriatric Depression Scale Short Form, and Apparent Emotion Rating Scale (AER) have been used to assess the effects of reminiscence on self-esteem, self-health perception, depressive symptoms, and mood status of elderly people residing in long-term care facilities and at home (Wang, 2004) . Regarding the effects of reminiscence therapy on dementia, a systematic review of four randomized controlled trials with a total of 144 patients concluded that reminiscence therapy could improve cognition and mood at follow-up and general behavior function at the end of the intervention period. Nevertheless, the individual studies were small and of relatively low study quality. Therefore, better designed trials are needed before more robust conclusions can be drawn (Woods et al., 2005). A more recent review on six randomized controlled trials concluded that reminiscence therapy could improve mood, well-being, and behavior in patients with dementia. However, the sample sizes of the participants in the intervention group ranged from only 5 to 36 (Cotelli et al., 2012). An extended development of the reminiscence therapy is the spiritual reminiscence developed by MacKinlay and Trevitt (2012). A main difference between reminiscence therapy and spiritual reminiscence is that the latter emphasizes on reconnecting and enhancing the meaning of one’s own experience and interactions with others. Spiritual reminiscence is a particular way of communication that acknowledges the importance of spirituality. It can help participants to explore and reframe their experience including anger, guilt, or regret, and to gain a new understanding of the meaning and purpose of their lives (MacKinlay and Trevitt, 2006). It should be noted that spirituality can be mediated in various ways such as through religion, relationship, environment, and the Int J Geriatr Psychiatry 2016; 31: 120–127
122
arts (MacKinlay and Trevitt, 2010). Therefore, spiritual reminiscence can be used on individuals who have a religious faith and also for those who have none. Previous randomized controlled trials have assessed the effects of reminiscence therapy on many outcome measures such as Mini Mental State Examination (MMSE), Clifton Assessment Procedures for the Elderly, Behavior Rating Scale for the Elderly, Holden Communication Scale, Quality of Life in Alzheimer’s Disease, Life Satisfaction Index, Well-being/Ill-being Scale, and Geriatric Depression Scale (Cotelli et al., 2012; Woods et al., 2005). Nevertheless, to our knowledge, no randomized controlled studies have evaluated the effectiveness of spiritual reminiscence on hope and spiritual well-being of elderly patients with mild and moderate dementia. Therefore, the aim of the present study was to investigate the effectiveness of a 6-week spiritual reminiscence for improving hope, life satisfaction, and spiritual well-being in elderly Taiwanese patients with mild or moderate dementia. Methods Study design and participants
A pre–post randomized controlled design was used to evaluate the effects of spiritual reminiscence on hope, life satisfaction, and spiritual well-being in elderly Taiwanese with mild and moderate dementia. Patients diagnosed with mild or moderate dementia were identified from the geriatric division of a medical center in central Taiwan. Patients were eligible if they were 65 years of age or more, had clinical diagnosis of mild or moderate dementia, were able to communicate in Mandarin or Taiwanese, had no discernible cognitive impairment, and were willing to participate in a weekly spiritual reminiscence for 6 weeks if being allocated to the intervention group or willing to participate in two interviews 6 weeks apart if being allocated to the control group. Mini Mental State Examination was used to screen potential participants. Scores between 21 to 24 indicate mild dementia and those between 13 to 20 indicate moderate dementia. A geriatric nurse was responsible for allocating eligible patients to either the intervention or control groups based on a recruitment sequence made up of random numbers. Spiritual reminiscence intervention
The spiritual reminiscence intervention consisted of six weekly sessions. Each session lasted for 1 h, which Copyright # 2015 John Wiley & Sons, Ltd.
L.-F. Wu and M. Koo
included warm-up greetings for 5 min, group activities for 50 min, and conclusion with blessings by the group leader for 5 min. The greeting period was used to introduce the theme of each session and to review the one from previous session. The sessions were carried out in an activity room of the study hospital. The activity room was a brightly lit, sizeable space with a warm and relaxed atmosphere. Patients were arranged to sit in a circle to allow them to have eye contact and communicate with others. Each group consisted of three to six patients. The group activities consisted of scrapbooks, handicraft, autobiographical writing, observing the growth of plants, storytelling, and singing. These activities were constructed around six different themes based on MacKinlay’s spiritual tasks of aging model (MacKinlay, 2001a; MacKinlay, 2001b;). The content of each session was developed based on the spiritual model of dementia by MacKinlay and Trevitt (2012) and a package designed for health care professionals to undertake spiritual reminiscence on patients with dementia (MacKinlay and Trevitt, 2006). All the interviews were administered outside the intervention setting by L. F. W., who were unaware of group allocation. Participants were provided with a manual containing written materials covered in each of the six sessions for their review. The six weekly themes were the following: Week 1: Meaning in life (What gives greatest meaning to your life now? Is life worth living, and if not, why not?), Week 2: Relationships, isolation and connecting (Do you feel that your relationships with others has changed with aging, and why?), Week 3: Hopes, fears and worries (Are there any things that make you worry? Are there any things that bring you hope?), Week 4: Growing older and transcendence (What is it like growing old? How do you adjust yourself to these changes?), Week 5: Spiritual and religious beliefs (Do you have any spiritual or religious beliefs? What kinds of religious activities have you participated?), and Week 6: Spiritual and religious practices (What have your spiritual or religious beliefs changed you? What kinds of help have religious activities brought to you?) Data collection and instruments
Three instruments, the Herth Hope Index, the Life Satisfaction Scale, and the Spirituality Index of WellBeing, were used for our main outcome measurement. In addition, the cognitive impairment severity of the patient was assessed with the MMSE. The instruments Int J Geriatr Psychiatry 2016; 31: 120–127
Spiritual reminiscence and dementia
were administered at baseline (beginning of the session in Week 1) (pre-test) and after intervention (end of the session in Week 6) (post-test). Sex, age, educational level, religious belief, and regularity of attending religious activities of the participants were ascertained. The Chinese version of the Herth Hope Index includes 12 items that measure various dimensions of hope (Herth, 1992). Each item is rated on a four-point Likert scale that ranges from “strongly disagree” (1 point) to “strongly agree” (4 points). A total score that can range from 12 to 48 is calculated, and higher scores indicate higher levels of hope. The Cronbach α for the Chinese version of the Herth Hope Index was reported to be 0.82 and 0.89 in a study of patients with leukemia (Chen and Wand, 1997) and lung cancer (Hsu et al., 2003), respectively. Life satisfaction was assessed using the Life Satisfaction Scale, in which the participants were asked whether they agree, disagree, or unsure regarding 18 statements regarding their sense of achievement and contentment with life. The Cronbach α for the Life Satisfaction Scale was reported to be 0.82 (Hwang and Chong, 1987). The scale was derived based on the Life Satisfaction Index A developed by Neugarten and colleagues (Neugarten et al., 1961). Possible scores range from 0 to 18 with higher scores indicate greater life satisfaction. The Spirituality Index of Well-Being is a 12-item instrument that measures the effect of spirituality on subjective well-being (Daaleman and Frey, 2004). The scale is divided into a self-efficacy subscale and a life-scheme subscale. Participants were asked to rate each item using a five-point scale ranging from strongly agree (1 point) to strongly disagree (5 points). The scale was reported to have good reliability with a Cronbach α of 0.91 and a test–retest correlation of 0.79 in a study on 509 adult outpatients. In addition, the scale had significant and expected correlations with several other instruments that measure wellbeing or spirituality including the Zung Depression Scale (r = 0.42), General Well-Being Scale (r = 0.64), and Spiritual Well-Being Scale (r = 0.62) (Daaleman and Frey, 2004). Written permission was obtained from Dr. Timothy P. Daaleman, the first author of the English version of the Spirituality Index of Well-Being (Daaleman and Frey, 2004) to translate the instrument into Chinese. Ethical considerations
The study protocol was approved by the institutional review board of the study site (protocol number Copyright # 2015 John Wiley & Sons, Ltd.
123
SE13297). All patients gave written consent after receiving both an oral and written explanation of the study’s objectives and procedures. Statistical analysis
Data were analyzed using IBM SPSS Statistics software package, version 22 for Windows (IBM Corp., Armonk, NY, USA). The basic characteristics of the patients were expressed at frequencies and percentages. Chi-squared test was used to compare the distribution of the basic characteristics between the intervention and control group. To take into account the within-subject correlation over time, generalized estimating equation models (Zeger and Liang, 1986) with autoregressive first-order working correlation matrix and robust standard error were used to evaluate the changes in the scores of the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the MMSE over time (post-test–pre-test) between the intervention and control groups. A significant interaction between group and time indicates that the changes over time between the intervention group and control group are different. All statistical tests were two sided, and P values of less than 0.05 were considered significant. Results A total of 106 patients were successfully recruited into the study and were randomly allocated to the intervention and control groups in equal numbers. However, three participants from the control group withdrew from the study after the interview at the baseline and thus leaving 50 controls for the final analysis. About a third of the patients were male patients and 56% of the patients were over 70 years of age. About 80% had an educational level of high school or less. Almost 60% of the patients believed in traditional folk religion and 69% regularly attending religious activities. All our patients had Alzheimer’s disease except one patient in the intervention group that was diagnosed with frontotemporal dementia. No significant differences in the basic characteristics at the baseline were found between the intervention and control groups, indicating that comparable groups were generated with the randomization process (Table 1). Table 2 provides the results before and after intervention in the scores for the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the MMSE. After six weekly spiritual reminiscence sessions, the mean scores of the Herth Int J Geriatr Psychiatry 2016; 31: 120–127
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Table 1 Basic characteristics of the study participants (N = 103) n (%) P
Variable Total 103 (100) Sex Male female Age (years) ≤70 71 74 ≥75 Mean (SD)
Intervention group 53 (51.5)
Control group 50 (48.5) 0.280
32 (31.1) 71 (68.9)
19 (35.8) 34 (64.2)
13 (26.0) 37 (74.0)
45 (43.7) 25 (24.3) 33 (32.0) 73.6 (7.4)
23 (43.4) 14 (26.4) 16 (30.2) 73.5 (7.3)
22 (44.0) 11 (22.0) 17 (34.0) 73.6 (7.6)
0.850
0.930
Educational level Elementary school High school University and above Religious belief None Buddhism Taoism Traditional folk religion Other
33 (32.0) 49 (47.6) 21 (20.4)
17 (32.1) 25 (47.2) 11 (20.8)
16 (32.0) 24 (48.0) 10 (20.0)
13 (12.6) 18 (17.5) 9 (8.7) 61 (59.2) 2 (1.9)
7 (13.2) 8 (15.1) 6 (11.3) 31 (58.5) 1 (1.9)
6 (12.0) 10 (20.0) 3 (6.0) 30 (60.0) 1 (2.0)
Attending religious activities Never Irregularly Regularly
21 (20.4) 11 (10.7) 71 (68.9)
10 (18.9) 6 (11.3) 37 (69.8)
11 (22.0) 5 (10.0) 34 (68.0)
52 (98.1) 1(1.9)
50 (100.0) 0
Types of dementia Alzheimer’s disease Frontotemporal dementia MMSE score at the baseline 21 24 (mild dementia) 13 20 (moderate dementia) Mean (SD)
0.995
0.873
0.915
>0.999 102 (99) 1(1)
0.193 93 (90.3) 10 (9.7) 23.0 (1.44)
50 (94.3) 3 (5.7) 23.1 (1.31)
43 (86.0) 7 (14.0) 22.9 (1.57)
0.582
SD: standard deviation; MMSE: Mini Mental State Examination. % are column percentages except in the header row where they are row percentages.
Table 2 Scores of the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the Mini-Mental State Examination in the spiritual reminiscence intervention and control groups at pre-test and post-test. P*
Mean (standard deviation) Outcome variable
Herth Hope Index Pre-test Post-test Life Satisfaction Index Pre-test Post-test Spirituality Index of Well-Being Pre-test Post-test MMSE Pre-test Post-test
Total
Intervention group
Control group
36.0 (4.1) 37.1 (4.5)
35.9 (4.1) 38.5 (4.6)
36.0 (4.1) 35.6 (3.8)
25.0 (5.6) 25.3 (5.5)
24.8 (5.8) 26.4 (5.7)
25.2 (5.4) 24.1 (5.0)
37.2 (7.2) 38.5 (7.7)
37.4 (7.4) 40.1 (8.0)
37.0 (7.1) 36.7 (7.1)
23.0 (1.4) 23.1 (1.7)
23.1 (1.3) 23.4 (1.6)
22.9 (1.6) 22.7 (1.7)
Group effect
Time effect
Interaction effect
0.866
0.005
Randomized controlled trial of a six-week spiritual reminiscence intervention on hope, life satisfaction, and spiritual well-being in elderly with mild and moderate dementia Li-Fen Wu1 and Malcolm Koo2,3 1
Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan 3 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Correspondence to: M. Koo, PhD, E-mail: [email protected] 2
Objective: Reminiscence therapy has been reported to improve the well-being in patients with dementia. However, few studies have examined the effects of spiritual reminiscence, which emphasizes on reconnecting and enhancing the meaning of one’s own experience, on patients with dementia. Therefore, this study aimed to investigate the effects of spiritual reminiscence on hope, life satisfaction, and spiritual well-being in elderly Taiwanese with mild or moderate dementia. Methods: A randomized controlled trial was conducted on 103 patients with mild or moderate dementia recruited from a medical center in central Taiwan. The patients were randomly assigned to either a 6-week spiritual reminiscence group (n = 53) or control group (n = 50). The Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being were administered before and after the 6-week period. Results: The interaction terms between group and time for the three outcome measures were found to be significant (P < 0.001), indicating that the changes over time in them were different between the intervention and control groups. Conclusions: Findings of this randomized controlled trial showed that hope, life satisfaction, and spiritual well-being of elderly patients with mild or moderate dementia could significantly be improved with a 6-week spiritual reminiscence intervention. Copyright # 2015 John Wiley & Sons, Ltd. Key words: spiritual; reminiscence therapy; complementary medicine; dementia; elderly History: Received 19 November 2014; Accepted 15 April 2015; Published online 11 May 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4300
Introduction Caring of patients with dementia is a critical public health issues in many parts of the world, particularly in those with aging populations (World Health Organization, 2012). It has been estimated that over 81 million people will be affected by dementia globally by 2040 (Ferri et al., 2005). The worldwide societal cost of dementia is estimated to be US$422 billion (Wimo et al., 2010). Results from a meta-analysis of Diagnostic and Statistical Manual of Mental Disorders IV diagnosed dementia indicated that the pooled prevalence Copyright # 2015 John Wiley & Sons, Ltd.
of dementia in people aged 60 years and over in mainland China, Hong Kong, and Taiwan is 4.6% (95% confidence interval: 3.4%, 5.8%) (Wu et al., 2013). Dementia is characterized by chronic and nonreversible deterioration in memory, loss of executive function, and changes in personality. It implies a long period of suffering for the patient and severe emotional and financial burden on the patient’s family and caregivers. In addition, mortality rates also increase as a result of various infectious complications associated with being bedridden at the end-stage of the disease. Many clinical trials have evaluated the Int J Geriatr Psychiatry 2016; 31: 120–127
Spiritual reminiscence and dementia
efficacy of various medications with mixed results (Olsen et al., 2005; Hansen et al., 2007). Generally, acetylcholinesterase inhibitors and memantine appeared to be marginally beneficial on the cognitive, behavioral, and psychological symptoms of dementia in some patients. The effectiveness of antipsychotic medications, benzodiazepines, antidepressants, and mood stabilizers is also unclear (Butler and Radhakrishnan, 2012). Besides pharmacological treatment, psychological interventions such as cognitive behavioral therapy along with usual care have been examined and found to be effective in reducing symptoms of depression and clinician-rated anxiety for people with dementia and therefore have the potential to improve patient well-being (Orgeta et al., 2014). Other nonpharmacologcal interventions such as music therapy (Vasionytė and Madison, 2013), aromatherapy (Forrester et al., 2014), massage (Viggo Hansen et al., 2006), and exercise programs (Forbes et al., 2013) have also been evaluated. However, because of the variation in the results between trials and methodological concerns, additional research is still required to demonstrate whether these interventions can improve the cognition, behavior, depression, and mortality in patients with dementia. Another psychological intervention in dementia care that has gained attention in recent years is the reminiscence therapy (Woods et al., 2005). According to Bluck and Levine (1998), reminiscence can be defined as “the volitional or non-volitional act or process of recollecting memories of one’s self in the past. It may involve the recall of particular or generic episodes that may or may not have been previously forgotten and that are accompanied by the sense that the remembered episodes are veridical accounts of the original experiences. This recollection from autobiographical memory may be private or shared with others.” Reminiscence therapy is defined by the American Psychological Association as “the use of life histories—written, oral, or both—to improve psychological well-being.” (Vandenbos, 2006). An early theory put forward for reminiscence therapy was the “disengagement theory” (Cumming and Henry, 1961), in which successful aging is viewed as a process of withdrawal from personal relationships and society. Under the “ego-integrity theory,” an individual who achieves ego-integrity through looking back on their life and accomplishments does not fear the uncertainty associated with death (Erikson, 1994). Butler (1963) extended the ego-integrity theory to the “continuity theory,” in which reminiscence is viewed as a way for an individual to adapt to changes that Copyright # 2015 John Wiley & Sons, Ltd.
121
occur in different stages of his or her life. Change is linked to the individual’s perceived past and therefore producing continuity in inner psychological characteristics. In addition, reminiscence group therapy may provide an opportunity for interaction and stimulation of a positive self-attitude among group members (Lin et al., 2003). In reminiscence therapy, patients are encouraged to talk about the past to bring past experiences into consciousness. However, reminiscence is more than simply recalling the past. It is reflexive process in which one can introspectively define or redefine oneself (Parker, 1995). Previous studies have used various indicators to measure the effects of reminiscence therapy on cognition, psychology, behavior, and health of elderly individuals. For example, Rosenberg’s SelfEsteem Scale, Health Perception Scale, Geriatric Depression Scale Short Form, and Apparent Emotion Rating Scale (AER) have been used to assess the effects of reminiscence on self-esteem, self-health perception, depressive symptoms, and mood status of elderly people residing in long-term care facilities and at home (Wang, 2004) . Regarding the effects of reminiscence therapy on dementia, a systematic review of four randomized controlled trials with a total of 144 patients concluded that reminiscence therapy could improve cognition and mood at follow-up and general behavior function at the end of the intervention period. Nevertheless, the individual studies were small and of relatively low study quality. Therefore, better designed trials are needed before more robust conclusions can be drawn (Woods et al., 2005). A more recent review on six randomized controlled trials concluded that reminiscence therapy could improve mood, well-being, and behavior in patients with dementia. However, the sample sizes of the participants in the intervention group ranged from only 5 to 36 (Cotelli et al., 2012). An extended development of the reminiscence therapy is the spiritual reminiscence developed by MacKinlay and Trevitt (2012). A main difference between reminiscence therapy and spiritual reminiscence is that the latter emphasizes on reconnecting and enhancing the meaning of one’s own experience and interactions with others. Spiritual reminiscence is a particular way of communication that acknowledges the importance of spirituality. It can help participants to explore and reframe their experience including anger, guilt, or regret, and to gain a new understanding of the meaning and purpose of their lives (MacKinlay and Trevitt, 2006). It should be noted that spirituality can be mediated in various ways such as through religion, relationship, environment, and the Int J Geriatr Psychiatry 2016; 31: 120–127
122
arts (MacKinlay and Trevitt, 2010). Therefore, spiritual reminiscence can be used on individuals who have a religious faith and also for those who have none. Previous randomized controlled trials have assessed the effects of reminiscence therapy on many outcome measures such as Mini Mental State Examination (MMSE), Clifton Assessment Procedures for the Elderly, Behavior Rating Scale for the Elderly, Holden Communication Scale, Quality of Life in Alzheimer’s Disease, Life Satisfaction Index, Well-being/Ill-being Scale, and Geriatric Depression Scale (Cotelli et al., 2012; Woods et al., 2005). Nevertheless, to our knowledge, no randomized controlled studies have evaluated the effectiveness of spiritual reminiscence on hope and spiritual well-being of elderly patients with mild and moderate dementia. Therefore, the aim of the present study was to investigate the effectiveness of a 6-week spiritual reminiscence for improving hope, life satisfaction, and spiritual well-being in elderly Taiwanese patients with mild or moderate dementia. Methods Study design and participants
A pre–post randomized controlled design was used to evaluate the effects of spiritual reminiscence on hope, life satisfaction, and spiritual well-being in elderly Taiwanese with mild and moderate dementia. Patients diagnosed with mild or moderate dementia were identified from the geriatric division of a medical center in central Taiwan. Patients were eligible if they were 65 years of age or more, had clinical diagnosis of mild or moderate dementia, were able to communicate in Mandarin or Taiwanese, had no discernible cognitive impairment, and were willing to participate in a weekly spiritual reminiscence for 6 weeks if being allocated to the intervention group or willing to participate in two interviews 6 weeks apart if being allocated to the control group. Mini Mental State Examination was used to screen potential participants. Scores between 21 to 24 indicate mild dementia and those between 13 to 20 indicate moderate dementia. A geriatric nurse was responsible for allocating eligible patients to either the intervention or control groups based on a recruitment sequence made up of random numbers. Spiritual reminiscence intervention
The spiritual reminiscence intervention consisted of six weekly sessions. Each session lasted for 1 h, which Copyright # 2015 John Wiley & Sons, Ltd.
L.-F. Wu and M. Koo
included warm-up greetings for 5 min, group activities for 50 min, and conclusion with blessings by the group leader for 5 min. The greeting period was used to introduce the theme of each session and to review the one from previous session. The sessions were carried out in an activity room of the study hospital. The activity room was a brightly lit, sizeable space with a warm and relaxed atmosphere. Patients were arranged to sit in a circle to allow them to have eye contact and communicate with others. Each group consisted of three to six patients. The group activities consisted of scrapbooks, handicraft, autobiographical writing, observing the growth of plants, storytelling, and singing. These activities were constructed around six different themes based on MacKinlay’s spiritual tasks of aging model (MacKinlay, 2001a; MacKinlay, 2001b;). The content of each session was developed based on the spiritual model of dementia by MacKinlay and Trevitt (2012) and a package designed for health care professionals to undertake spiritual reminiscence on patients with dementia (MacKinlay and Trevitt, 2006). All the interviews were administered outside the intervention setting by L. F. W., who were unaware of group allocation. Participants were provided with a manual containing written materials covered in each of the six sessions for their review. The six weekly themes were the following: Week 1: Meaning in life (What gives greatest meaning to your life now? Is life worth living, and if not, why not?), Week 2: Relationships, isolation and connecting (Do you feel that your relationships with others has changed with aging, and why?), Week 3: Hopes, fears and worries (Are there any things that make you worry? Are there any things that bring you hope?), Week 4: Growing older and transcendence (What is it like growing old? How do you adjust yourself to these changes?), Week 5: Spiritual and religious beliefs (Do you have any spiritual or religious beliefs? What kinds of religious activities have you participated?), and Week 6: Spiritual and religious practices (What have your spiritual or religious beliefs changed you? What kinds of help have religious activities brought to you?) Data collection and instruments
Three instruments, the Herth Hope Index, the Life Satisfaction Scale, and the Spirituality Index of WellBeing, were used for our main outcome measurement. In addition, the cognitive impairment severity of the patient was assessed with the MMSE. The instruments Int J Geriatr Psychiatry 2016; 31: 120–127
Spiritual reminiscence and dementia
were administered at baseline (beginning of the session in Week 1) (pre-test) and after intervention (end of the session in Week 6) (post-test). Sex, age, educational level, religious belief, and regularity of attending religious activities of the participants were ascertained. The Chinese version of the Herth Hope Index includes 12 items that measure various dimensions of hope (Herth, 1992). Each item is rated on a four-point Likert scale that ranges from “strongly disagree” (1 point) to “strongly agree” (4 points). A total score that can range from 12 to 48 is calculated, and higher scores indicate higher levels of hope. The Cronbach α for the Chinese version of the Herth Hope Index was reported to be 0.82 and 0.89 in a study of patients with leukemia (Chen and Wand, 1997) and lung cancer (Hsu et al., 2003), respectively. Life satisfaction was assessed using the Life Satisfaction Scale, in which the participants were asked whether they agree, disagree, or unsure regarding 18 statements regarding their sense of achievement and contentment with life. The Cronbach α for the Life Satisfaction Scale was reported to be 0.82 (Hwang and Chong, 1987). The scale was derived based on the Life Satisfaction Index A developed by Neugarten and colleagues (Neugarten et al., 1961). Possible scores range from 0 to 18 with higher scores indicate greater life satisfaction. The Spirituality Index of Well-Being is a 12-item instrument that measures the effect of spirituality on subjective well-being (Daaleman and Frey, 2004). The scale is divided into a self-efficacy subscale and a life-scheme subscale. Participants were asked to rate each item using a five-point scale ranging from strongly agree (1 point) to strongly disagree (5 points). The scale was reported to have good reliability with a Cronbach α of 0.91 and a test–retest correlation of 0.79 in a study on 509 adult outpatients. In addition, the scale had significant and expected correlations with several other instruments that measure wellbeing or spirituality including the Zung Depression Scale (r = 0.42), General Well-Being Scale (r = 0.64), and Spiritual Well-Being Scale (r = 0.62) (Daaleman and Frey, 2004). Written permission was obtained from Dr. Timothy P. Daaleman, the first author of the English version of the Spirituality Index of Well-Being (Daaleman and Frey, 2004) to translate the instrument into Chinese. Ethical considerations
The study protocol was approved by the institutional review board of the study site (protocol number Copyright # 2015 John Wiley & Sons, Ltd.
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SE13297). All patients gave written consent after receiving both an oral and written explanation of the study’s objectives and procedures. Statistical analysis
Data were analyzed using IBM SPSS Statistics software package, version 22 for Windows (IBM Corp., Armonk, NY, USA). The basic characteristics of the patients were expressed at frequencies and percentages. Chi-squared test was used to compare the distribution of the basic characteristics between the intervention and control group. To take into account the within-subject correlation over time, generalized estimating equation models (Zeger and Liang, 1986) with autoregressive first-order working correlation matrix and robust standard error were used to evaluate the changes in the scores of the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the MMSE over time (post-test–pre-test) between the intervention and control groups. A significant interaction between group and time indicates that the changes over time between the intervention group and control group are different. All statistical tests were two sided, and P values of less than 0.05 were considered significant. Results A total of 106 patients were successfully recruited into the study and were randomly allocated to the intervention and control groups in equal numbers. However, three participants from the control group withdrew from the study after the interview at the baseline and thus leaving 50 controls for the final analysis. About a third of the patients were male patients and 56% of the patients were over 70 years of age. About 80% had an educational level of high school or less. Almost 60% of the patients believed in traditional folk religion and 69% regularly attending religious activities. All our patients had Alzheimer’s disease except one patient in the intervention group that was diagnosed with frontotemporal dementia. No significant differences in the basic characteristics at the baseline were found between the intervention and control groups, indicating that comparable groups were generated with the randomization process (Table 1). Table 2 provides the results before and after intervention in the scores for the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the MMSE. After six weekly spiritual reminiscence sessions, the mean scores of the Herth Int J Geriatr Psychiatry 2016; 31: 120–127
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Table 1 Basic characteristics of the study participants (N = 103) n (%) P
Variable Total 103 (100) Sex Male female Age (years) ≤70 71 74 ≥75 Mean (SD)
Intervention group 53 (51.5)
Control group 50 (48.5) 0.280
32 (31.1) 71 (68.9)
19 (35.8) 34 (64.2)
13 (26.0) 37 (74.0)
45 (43.7) 25 (24.3) 33 (32.0) 73.6 (7.4)
23 (43.4) 14 (26.4) 16 (30.2) 73.5 (7.3)
22 (44.0) 11 (22.0) 17 (34.0) 73.6 (7.6)
0.850
0.930
Educational level Elementary school High school University and above Religious belief None Buddhism Taoism Traditional folk religion Other
33 (32.0) 49 (47.6) 21 (20.4)
17 (32.1) 25 (47.2) 11 (20.8)
16 (32.0) 24 (48.0) 10 (20.0)
13 (12.6) 18 (17.5) 9 (8.7) 61 (59.2) 2 (1.9)
7 (13.2) 8 (15.1) 6 (11.3) 31 (58.5) 1 (1.9)
6 (12.0) 10 (20.0) 3 (6.0) 30 (60.0) 1 (2.0)
Attending religious activities Never Irregularly Regularly
21 (20.4) 11 (10.7) 71 (68.9)
10 (18.9) 6 (11.3) 37 (69.8)
11 (22.0) 5 (10.0) 34 (68.0)
52 (98.1) 1(1.9)
50 (100.0) 0
Types of dementia Alzheimer’s disease Frontotemporal dementia MMSE score at the baseline 21 24 (mild dementia) 13 20 (moderate dementia) Mean (SD)
0.995
0.873
0.915
>0.999 102 (99) 1(1)
0.193 93 (90.3) 10 (9.7) 23.0 (1.44)
50 (94.3) 3 (5.7) 23.1 (1.31)
43 (86.0) 7 (14.0) 22.9 (1.57)
0.582
SD: standard deviation; MMSE: Mini Mental State Examination. % are column percentages except in the header row where they are row percentages.
Table 2 Scores of the Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being, and the Mini-Mental State Examination in the spiritual reminiscence intervention and control groups at pre-test and post-test. P*
Mean (standard deviation) Outcome variable
Herth Hope Index Pre-test Post-test Life Satisfaction Index Pre-test Post-test Spirituality Index of Well-Being Pre-test Post-test MMSE Pre-test Post-test
Total
Intervention group
Control group
36.0 (4.1) 37.1 (4.5)
35.9 (4.1) 38.5 (4.6)
36.0 (4.1) 35.6 (3.8)
25.0 (5.6) 25.3 (5.5)
24.8 (5.8) 26.4 (5.7)
25.2 (5.4) 24.1 (5.0)
37.2 (7.2) 38.5 (7.7)
37.4 (7.4) 40.1 (8.0)
37.0 (7.1) 36.7 (7.1)
23.0 (1.4) 23.1 (1.7)
23.1 (1.3) 23.4 (1.6)
22.9 (1.6) 22.7 (1.7)
Group effect
Time effect
Interaction effect
0.866
0.005
