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SYSTEMATIC REVIEW

A Systematic Review of Reminiscence Therapy for Older Adults in Taiwan

Yen, Hsin-Yen1; Lin, Li-Jung2*

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doi: 10.1097/jnr.0000000000000233
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Abstract

Introduction

Healthy aging is an important issue globally. The number of people aged 65 years and above worldwide has increased from 524 million in 2010 to 1.5 billion in 2050. The cost of healthcare for this older population has become a huge social burden (World Health Organization, 2011). Thus, the health status and health promotion issues of older adults are of critical concern. More than 26% of older adults experience at least one mental or neurological disorder or disability. The most common neuropsychiatric disorders in older adults are dementia, depression, anxiety, and substance abuse problems. Health, social services, and long-term care play important roles in promoting mental health in older adults (World Health Organization, 2015).

However, adults in the maturity stage of Erickson’s life stage (> 65 years old) have undergone the “ego integrity vs. despair” process. During this stage, older adults develop integrity and cope with their feelings about life events (Erikson, 1959). Social isolation and exclusion are also common problems during this stage. Common objectives of older adults include adapting to the social environment, enjoying support, and being empowered to live and die with dignity (World Health Organization, 2015). Reminiscence therapy may help older adults review their memories, experiences, and accomplishments to age successfully and to face death.

Reminiscence therapy is a popular intervention for older people in dementia care, long-term care, and hospice care (Cotelli, Manenti, & Zanetti, 2012). The reminiscence technique has been used extensively since the 1960s by professional practitioners such as psychologists, nursing staff, social workers, and recreational therapists. Reminiscence therapy is usually used as a treatment and an intervention for the older adults because of its nonpharmacological nature. Reminiscence therapy has been shown to have a positive impact on older patients with and without mental health problems (Syed Elias, Neville, & Scott, 2015; Woods, Spector, Jones, Orrell, & Davies, 2005).

Reminiscence is defined as an action or process of recalling the past, which may occur in people of any age. Reminiscence therapy may involve sharing in a group setting or in the presence of one observer who listens quietly without comment (Butler, 1963). Reminiscence is an internalized behavior in which “there is often an interplay, a ‘dialectic,’ between an individual’s internal mental processes and external manifestations of thought” (Parker, 1995). Although not everything that is thought internally is expressed externally, people who review life events tend to select stories that reflect their values. Therefore, the reminiscence process may be completed on two different levels: intrapersonally (internally) or interpersonally (in a dyad or group). When people talk about their past to others, they not only ruminate or introspect about what they believe and value in the relationships among self-relevant events across time but also reconstruct an interpersonal context by obtaining input from others and achieving reciprocity or an exchange of ideas. This process contributes to developing, maintaining, or reconstructing personal identity (Parker, 1995).

In general, three global functions may be used to examine reminiscence as a mechanism for continuity: self-focus (coherence and meaning), guidance (knowledge based), and social bonding (emotion management; Cappeliez, Rivard, & Guindon, 2007). In addition, describing negative feelings that were induced by a tragedy and then releasing the related grief with support from others may provide psychological relief for the individual. Although cognitive capacity may decrease with age or disease, older adults may enhance cognitive performance by exercising memory systems and by improving plasticity via reminiscence. Undoubtedly, individuals keep past memories stored in the brain, even as particular areas are gradually impaired. Reminiscence may be the key to unfolding memories and to making “the past become a rich resource of living in the present and anticipating the future” (Gibson & Burnside, 2005, p. 175).

Lin, Dai, and Hwang (2003) first proposed the framework of reminiscence therapy. Reminiscence therapy is a process that includes several stages: antecedent, assessment setting the therapeutic purpose, choosing the therapy modality (simple reminiscence or life review), and outcome measurement. Most of the previous studies examining the effectiveness of reminiscence therapy have focused on the improvement of depression and anxiety, interactions and communications, positive affect, life satisfaction, self-esteem, and cognitive functions (Cotelli et al., 2012; Pinquart & Forstmeier, 2012; Song, Shen, Xu, & Sun, 2014).

The themes and materials that have been used in reminiscence therapy differ from country to country because of cultural differences. This study was conducted in Taiwan, subject to Japanese rule for 50 years, between 1895 and 1945. The Republic of China has governed Taiwan since 1945. Thus, Taiwan has a multicultural society that has been influenced significantly in modern times by Chinese, Japanese, and indigenous Malayo-Polynesian cultures. Many of Taiwan’s older adults have experienced wars, food shortages, resource shortages, poverty, and imposed patriotism (Rubinstein, 2015). These life events were important parts of the childhoods of these older adults. Therefore, the themes and materials of reminiscence should reflect the history, personal background and experiences, and shared memories, and remembrance therapy should be tailored to the context of older Taiwanese.

Few studies on the application of reminiscence approaches in populations of frail older adults have been published in gerontology or nursing care journals in Taiwan. The research designs, reminiscence intervention designs, and outcomes all differ significantly among previous studies. Therefore, the aim of the current study was a systematic review of reminiscence therapy interventions and outcomes in Taiwan, the experimental and intervention designs that were used in previous studies, and the distinctive contents of reminiscence programs that are currently used for Taiwanese older adults. In addition, this study attempted to identify the benefits and effectiveness of reminiscence therapy in this population. The results may be used to guide the design of reminiscence therapies for future studies and clinical application.

Methods

A synthesis matrix was used to conduct the systematic review. A synthesis matrix is a literature review method that is widely applied in the health sciences. The matrix box is composed of rows and columns, with the rows comprising literature and the columns comprising topics and variables of interest to the researchers. The abstracts, summary, and points of articles are included in a synthesis matrix. A synthesis matrix is also a critical analysis method that is used to develop future research (Garrard, 2006).

This study used the search terms “reminiscence,” “dementia,” “Alzheimer’s disease,” and “Taiwan” in an Integrated Resources Search that was conducted through the National Taiwan Normal University. The search covered several databases, including Taylor and Francis, Ltd.; Springer Science; Science Direct; Sage Publications, Inc.; and Elsevier, Ltd., among others. The search focused on articles published between 2004 and 2016. Two reviewers conducted the systematic review. The first was a doctoral student in a graduate institute of sport and leisure and a registered nurse in Taiwan with psychiatric nurse experience. The second was an associate professor in the same graduate institute who held a doctorate in Parks, Recreation, and Leisure and therapeutic recreation specialist and horticultural therapist certifications from the United States. The two reviewers selected, cross-compared, and discussed the articles together to ensure accuracy.

To explore the implementation and effectiveness of reminiscence therapy in Taiwan, several criteria were used in the selection process. First, all selected articles used evidence-based interventions and were not theoretical, introductory, or review articles. Second, all experiments used in the selected articles were conducted in Taiwan regions in either institutional or noninstitutional settings such as older adult care facilities, medical centers, nursing homes, and community and other healthcare institutions. Third, reminiscence therapy was the intervention in all of the selected articles. Studies that used music therapy and art therapy in patients with dementia were excluded. Experimental, nonexperimental, and qualitative studies were included. Finally, participants in the selected studies were all 65 years or older. Overall, 20 articles were identified by the Integrated Resources Search. Four of these were excluded from the final review; two addressed unrelated topics, and the remaining two were literature reviews.

Results

Sixteen articles were reviewed using two different synthesis matrices (intervention and experimental designs). Issues discussed in the articles using experimental designs were assessed with regard to type of reminiscence intervention approach used, intervention frequency, group size, reminiscence topic/theme, evocative materials, and training procedures (see Table 1).

TABLE 1.
TABLE 1.:
Description of the Interventions Used in the Reviewed Studies

Group Size

Most of the studies in the review implemented group reminiscence therapy, whereas three studies adopted one-on-one programs (Chao et al., 2008; Wang, 2004, 2005). The most common group sizes ranged from 7 to 12 participants, although Su et al. (2012) had the largest groups, with 25–26 participants each. Group size was not recorded in two of the studies (Chiang et al., 2008, 2010).

Frequency

Eight to 16 sessions were held over a 4- to 16-week period. Reminiscence sessions were held once or twice a week. Most of the interventions conducted eight sessions over 8 consecutive weeks, with a frequency of one session per week. The duration of each reminiscence session was between 30 minutes and 2 hours. In most of the studies, reminiscence was 60 minutes per session. The most frequent session was administered in 72 successive sessions at three times per week over a 3-month period (Su et al., 2012).

The Content of Reminiscence

Structured, unstructured, and life review approaches were used in the reviewed studies. Themes and topics focused on childhood experiences, marriage, family life, and jobs. Other themes focused on identifying meaning in life, future goals, fears of death, and expressing personal feelings.

Unspecified discussions based on evocative materials were prevalent. However, Huang et al. (2009) used cooking lessons only to stimulate the senses of older adults to evoke memories through food. Images and sounds were commonly used as evocative materials and stimuli. Several studies asked participants and their family members to collect old belongings to share with the group (Chao et al., 2008; Chiang et al., 2008). Because of Taiwanese history, many evocative materials dated from the Japanese Colonial Period and included folk items such as lullabies; traditional toys; folk music tapes, records, and movies; and tea art. These made it easier for the participants to recall memories of past experiences.

Only two of the studies applied a life review intervention (Chiang et al., 2008; Lin et al., 2011). Life review is a spontaneous, universal mental process that involves the evaluation and resynthesis of past experiences, in particular, unresolved conflicts. It is necessary for individuals to reintegrate the experiences of life to adapt to old age; cope with loss, guilt, conflict, or defeat; and help find meaning in their accomplishments (Butler, 1963; Haber, 2006). On the basis of Erikson’s theory, a professional using a structured program is able to systematically evoke the salient memories from each stage of the life cycle of an older person.

Facilitators

Two people are typically needed to conduct group sessions (Chao et al., 2006, 2008; Wang, 2007; Wang et al., 2009). The leader and co-leader of the program and the reminiscence facilitator were usually registered nurses, social workers, recreation therapists, or healthcare providers with experience in geriatric care. However, most of the studies did not identify background or profession of the program leader. Only five studies provided training for the program leader (Hsu & Wang, 2009; Su et al., 2012; Wang, 2005, 2007; Wang et al., 2009).

Second is the result of a synthesis matrix of research designs. Research design is a critical factor for developing future, qualified studies. Several usable items of information on reminiscence research designs were provided by the reviewed studies. All articles were reviewed using the following topics: participants and settings, study design, outcome indicators, and findings (Table 2).

TABLE 2.
TABLE 2.:
Summary Descriptions of the Reviewed Studies

Participants and Setting

Two major groups were recruited for these studies, older adults with dementia and older adults without dementia or with no cognitive impairment, with each reflecting distinct research purposes. Five studies focused on patients with mild to moderate dementia (Huang et al., 2009; Lin et al., 2011; Su et al., 2012; Wang et al., 2009; Wu & Koo, 2016), and only one study expanded the intervention to include severe dementia (Wang, 2007). On the other hand, participants without dementia were identified using either the Mini Mental State Examination (MMSE) or psychiatric diagnoses.

All of the studies recruited a sample of between 7 and 103 participants. Three studies had small sample sizes of 7–10 participants (Chao et al., 2008; Huang et al., 2009; Lin et al., 2011), two had 20–30 participants (Chao et al., 2006; Chueh & Chang, 2014), three had 45–48 participants (Hsu & Wang, 2009; Wang, 2004, 2005), three had 75–77 participants (Chiang et al., 2008; Wang et al., 2009; Wu, 2011), and five had even larger sample sizes, from 92 to 103 participants (Chiang et al., 2010; Su et al., 2012; Wang, 2007; Wang et al., 2005; Wu & Koo, 2016).

The studies targeted recruitment efforts in healthcare facilities, including the gerontology departments of medical centers, long-term care facilities, nursing homes, and a sanatorium. Most of the studies employed purposive sampling in long-term care facilities. Nine of the studies recruited participants from only one long-term care institution, and seven recruited participants from two different healthcare institutions. Three of the reviewed studies recruited veterans exclusively (Chiang et al., 2008; Chueh & Chang, 2014; Wu, 2011). Finally, Wang (2004) compared institutionalized and noninstitutionalized older adults.

Experimental Design

Randomized controlled trials (RCTs) have been recommended as a strong research design for topics in patient care because of the power and reliability of results (Begg et al., 1996). However, few reminiscence studies have applied RCT (Chiang et al., 2008; Wang, 2007; Wang et al., 2009; Wu & Koo, 2016). Those that used RCT were mostly studies with large sample sizes. All the remaining studies used quasi-experimental designs. For example, only one experiment group was used, or participants were not divided randomly because of the small sample size. Furthermore, pretests and posttests were commonly used in the reviewed studies. Finally, three of the studies conducted a follow-up test 1–3 months after the intervention (Chiang et al., 2008, 2010; Chueh & Chang, 2014).

Outcome Indicators

Most of the studies collected quantitative data to examine the effectiveness of reminiscence on daily functioning, cognition, depression, mood status, self-esteem, and life satisfaction. However, only one of the studies, in which a nurse was both the investigator and the leader of reminiscence activity, used the qualitative method of participant observation to clarify the process and the meanings of reminiscence (Chao et al., 2008).

Most of the studies adopted subjective psychosocial measurements, including the Geriatric Depression Scale–Short Form and Self-esteem, Life Satisfaction, and Health Perception Scales, or objective performance assessments (e.g., MMSE and Activities of Daily Living [ADL]) to detect intervention-related changes. Other common measurement instruments that were not adopted included the Apparent Emotion Rating Scale, Loneliness Scale, Behavioral Rating Scale, Medical Outcomes Study, 36-Item Short Form Healthy Survey (MOS SF-36), Clinical Dementia Rating Scale, Short Portable Mental State Questionnaire, and Herth Hope Index. However, Huang et al. (2009) examined differences in electroencephalography (EEG) waves.

Findings

Reminiscence therapy has been shown to improve depressive symptoms and mood status. Wang (2004, 2005) and Wang et al. (2005) showed that reminiscence therapy had significant, positive influences on self-health perception, depressive symptoms, and mood status in institutionalized older people. Wang (2007), Hsu and Wang (2009), and Wang et al. (2009) identified significant improvements in cognition functions, mood and affection, social disturbance, and depressive symptoms. However, no significant difference was identified in terms of group effects on overall behavior competence or ADL. Chueh and Chang (2014) and Su et al. (2012) showed that the experimental group with reminiscence therapy significantly improved in terms of depressive symptoms and geriatric depression in both the posttest and follow-up test. However, no significant change was detected in terms of cognitive status rating, MMSE, or Clinical Dementia Rating Scale level.

Reminiscence therapy was found to influence self-esteem and life satisfaction positively. Chao et al. (2008) showed a significant improvement in self-esteem but insignificant differences in depression and life satisfaction. Chiang et al. (2010) and Wu (2011) found that experimental groups improved significantly in terms of self-esteem, life satisfaction, and depression.

Reminiscence therapy was shown to benefit the mental health of older persons. Chiang et al. (2010) applied structured reminiscence and showed significant improvements in depressed mood, psychological well-being, and feelings of loneliness. Lin et al. (2011) found improved mental health, including vitality, social functioning, emotional role, and physical role in physical health. Wu and Koo (2016) found that all indicators had increased significantly in the experimental group, including the Herth Hope Index, Life Satisfaction Scale, Spirituality Index of Well-Being, and MMSE. Huang et al. (2009) determined that reminiscence therapy significantly improved the EEG slow and fast waves, personal interaction scale, and feelings of participants, but there were only insignificant improvements for MMSE scores and depression.

Chao et al. (2006) applied a group reminiscence intervention in developing the framework of reminiscence therapy using observation as their method of study. The information collected included the personal characteristics of the residents, the content of the reminiscence, settings and triggers or catalysts, the verbal and nonverbal reactions of residents, and the thoughts and feelings of researchers. The result described the reminiscence process in four stages: entrée, immersion, withdrawal, and closure. Triggers in initiation included auditory and visual. The inducer and active listeners played important roles during the entrée stage.

Several items of evidence from previous studies show the psychological benefits of using reminiscence in older populations. First, significantly higher posttest MMSE scores (Wang, 2007; Wu & Koo, 2016) and faster EEG waves (Huang et al., 2009) indicate improvement in cognitive function. Second, depressive symptoms tended to decrease and mood status tended to improve in the treatment groups (Chueh & Chang, 2014; Hsu & Wang, 2009; Su et al., 2012; Wang, 2005, 2007; Wang et al., 2005). Third, significant improvements in personal interaction (Huang et al., 2009) and self-esteem (Chao et al., 2006; Chiang et al., 2008) were observed.

Discussion

Reminiscence therapy acts as a vehicle for older adults to recall their experiences and specific life events and to explore the meanings and influence on the future behavior of individuals who have these memories (Gibson & Burnside, 2005; Parker, 1995). Careful examination and discussion of reminiscence may help older adults reintegrate their life strengths and accomplishments and apply them to the present (Cappeliez et al., 2007). Several studies have confirmed that reminiscence therapy influences cognition (Huang et al., 2009; Wang, 2007; Wu & Koo, 2016), mood/emotions (Chueh & Chang, 2014; Hsu & Wang, 2009; Su et al., 2012; Wang, 2005, 2007; Wang et al., 2005), social interaction (Huang et al., 2009), and psychological well-being in older adults.

However, several improvements should be incorporated into research designs and processes. First, the benefits of recruiting from a single institution include convenience for the researchers and homogeneity among participants due to shared institutional experiences and similar lifestyles (Lin et al., 2011). However, studies with larger sample sizes may recruit participants from multiple institutions. In future studies, the recruiting process should be based on intervention designs that are valid with larger and smaller group sizes. Furthermore, participant characteristics should be considered in future studies. Most of the studies emphasized the importance of recruiting a sufficiently large sample size (Chiang et al., 2008; Lin et al., 2011; Wu & Koo, 2016).

Second, with regard to study design, RCTs are recommended for all future studies on this topic. RCTs are usually intended for use with larger sample sizes because of the requirement of assigning sufficient numbers of participants to experimental and control groups (Chiang et al., 2008; Wang, 2007; Wang et al., 2009; Wu & Koo, 2016). Most of the studies did not randomize participant assignments to two comparison groups. These studies not only measured the effectiveness of the interventions using pretest and posttest measures but also instituted follow-up measures after 1–3 months. The objective of reminiscence therapy is sustained improvement over the long term (Lin et al., 2011).

Third, the quantitative research method was a common approach used in the reminiscence therapy studies that were reviewed. Reliable and valid questionnaires and inventories such as Geriatric Depression Scale–Short Form; Self-esteem, Life Satisfaction, and Health Perception Scales; MMSE; and ADL were used as measurement tools and outcome indicators (Chao et al., 2006; Su et al., 2012; Wang et al., 2009; Wu, 2011; Wu & Koo, 2016). Suitable research instruments should be selected based on the character of the participants and the purpose of the study. In addition, the qualitative method may be adopted to collect richer psychological information on participants via in-depth interviews and observations (Chao et al., 2008).

Other suggestions elicited from our review of previous reminiscence therapy studies are as follows. A group size of 7–12 participants is common and considered ideal in group reminiscence therapy. Group reminiscence therapy is beneficial because Chinese older adults tend to be more reluctant to interact in social groups (Wang, 2005). A small group setting may allow the group leader to more readily implement and control the reminiscence therapy process, providing more opportunities to note reactions, performances, feedback, and the safety of older subjects to ensure that all have equal opportunity to participate. On the other hand, individual reminiscence therapy was also used in several studies (Chao et al., 2008; Wang, 2004, 2005). Although this approach to therapy likely costs more in terms of time and lacks interaction among group members, individual (one-on-one) reminiscence therapy may better facilitate the relationship between participants and the leader (Wang, 2004, 2005).

The frequency of intervention sessions should be considered for reminiscence therapy designs. The reviewed studies typically conducted interventions once or twice a week over a 3-month period. Each intervention session was approximately 60 minutes long, depending on group size and on the attention and interest of participants (Chao et al., 2006; Chueh & Chang, 2014; Hsu & Wang, 2009; Wang, 2007).

Before instituting a reminiscence intervention, the condition of older adult participants, including mental health, physical health, social interaction, and mood status, should be considered. Two people are typically needed to conduct the program in the group format. Training the facilitator before leading a reminiscence intervention is advised to ensure sufficient levels of expertise in the techniques and to manage the quality of the intervention program (Chao et al, 2006, 2008; Wang, 2007; Wang et al., 2009). During the intervention program, the leader should pay special attention to participants with cognitive impairments or unstable emotional conditions. Appointing healthcare providers as group leaders or holding interventions at healthcare institutions should be considered.

Initially, it may be difficult to start the intervention program smoothly because participants may not be familiar with one another. The facilitator should lead older adults to introduce themselves, and participants should be encouraged to share their thoughts, memories, and feelings in each following session. Interactions among participants during the intervention may improve their behaviors, acceptance, and the effectiveness of results. The intervention should be conducted in an environment that is quiet and safe and fosters an atmosphere of trust (Chao et al., 2008; Lin et al., 2011).

The content of reminiscence therapy may be designed differently based on participant characteristics such as age, gender, life habits, hometown or home area, and so on. The facilitators may use different materials evocative of reminiscence that dovetail with the topics under discussion. Specific reminiscence themes that were designed for Taiwanese older adults in the reviewed studies included the hardships of war (Wang, 2004); Taiwanese festivals, Chinese traditional food, and old-style entertainments (Chiang et al., 2010; Hsu & Wang, 2009; Wang, 2007; Wang et al., 2009); and experience with leprosy (Su et al., 2012). The Life Review Program for Taiwanese was designed to help participants recall past events such as childhood experiences, marriage, family life, and jobs, using photos, recordings, and radio programs as the evocative materials (Wang, 2004, 2005). On the other hand, Taiwanese cultural facets such as Japanese and Taiwanese folk songs, tapes, records, radio programs, and movies; firecrackers; special snacks; traditional festival food; folk toys; tea art; and cooking lessons should be incorporated as evocative materials used in reminiscence interventions (Chao et al., 2006; Hsu & Wang, 2009; Wang, 2004; Wang et al., 2005).

It is important that both structured and unstructured reminiscence interventions set a theme and a goal for the intervention at the beginning of sessions (Lin et al., 2011). Setting a goal makes the associated process more directive and proactive and helps the leader to execute a program more effectively. If the reminiscence therapy is effective in the group setting, the duration may be prolonged to incorporate reminiscence into the regular routine of participants.

In conclusion, this systematic review looked at previous studies about reminiscence interventions. These studies showed that Taiwanese culture-specific reminiscence therapies are able to improve the mental and physical health of subjects in the realms of quality of life, cognitive functions, and depressive status, although not every indicator in every study improved significantly (Chao et al., 2006; Huang et al., 2009; Su et al., 2012; Wang, 2004, 2007; Wang et al., 2009). Further studies are necessary to establish evidence-based protocols and systemic effectiveness for interventions that use reminiscence. However, the reviewed studies identified no negative postintervention impacts on participants. The authors have no doubt that reminiscence therapy is an effective, side-effect-free approach for promoting mental health in older adults. Reminiscence, currently widely used as a noninvasive intervention in the treatment of mentally ill older adults in Taiwan, is thus also recommended as a therapeutic treatment for older adults, especially those living in institutions.

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Keywords:

life review program; dementia; gerontology; psychiatry; mental health

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