Evidence-based Non-drug Treatments in Dementia – Reminiscence Therapy

Dementia is a progressive disease, with non-cognitive symptoms emerging at a far greater rate as the person ages. Dementia causes significant emotional, psychological and structural turmoil for all involved, with a projected total of  150 million dementia sufferers by 2050, of whom 80% will have dementia of Alzheimer’s disease (Morales-de-Jesús et al., 2021). Because the beneficial effects of medications are very limited, there is an increasing move to non-pharmacological therapies to treat people with dementia (Gonzalez et al., 2015; Van Bogaert et al., 2016).

One notable example of this non-drug approach is reminiscence therapy (RT) which was originally proposed by Robert N. Butler, an American geriatric psychiatrist, in 1963. (Tanaka et al., 2007)

Reminiscence therapy is a psycho-social programme which seeks to re-establish a self-image through the re-connection with and importing of memories and experiences from a person’s past life, thereby creating a contemporary sense of worthiness, well-being and life coherence. (Klever, 2013) Hence, this therapy seeks to place a memory anchor in the past so as to bolster and redevelop the person’s sense of contemporary worth. (Kelly & Ahessy, 2021)   

As defined by Woods et al. (2005) “Reminiscence Therapy (RT) involves the discussion of past activities, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings.”

How RT is implemented:

 The RT program for older patients with dementia can involve 10 weekly sessions, each lasting 60 minutes and, in some research, is led by a psychologist. The sessions are adapted to the personal and cognitive capacities of the patients.   In each session, all of the stages of life are engaged with using different topics.

A Spanish program employed the same structure for each session. First, each member of the group was welcomed, then the topic for the session was announced.

Session topics can include childhood experiences, favourite foods, favourite travel destinations earlier in life, important personal events (marriage, birth of children, work achievements, etc.), significant historical events during the person’s life (the moon landing, the assassination of JFK, the life of Queen Elizabeth II, or other culturally relevant milestones).    

The patient is actively encouraged to share these memories with the group.

The group leader provides and nurtures an inclusive, non-judgemental environment which will encourage openness in dialogue and thereby add to each person’s sense of value, worth and dignity. The facilitator’s role is vital. They seek to reduce the use of negative memories and emotions and, instead, enhance interpersonal relationships and a positive sense of self. The facilitator should seek to import positive memories and feelings from the past and re-anchor them in the present, thereby promoting personal identity. (Gonzalez et al., 2015; Lök et al., 2019)

Intended benefits:

The intended benefits of RT are multi-layered and affect dementia patients differently.

For example, Cotelli et al. (2012) reported that RT yielded improvement in mood, well-being, behaviour, a better quality of life (QoL) for both the patient and their caregivers and a reduction in depressive states. Also, an improvement in autobiographical memory was reported. Notwithstanding these benefits, the authors lamented that (at that time) only a small number of trials had been conducted, and they were of poor quality.

Saragih et al. (2022) have proposed that the improved QoL from RT is due to a variety of factors. These include:

• Happiness when people with dementia recall their past life;
• A sense of social support due to interactions with peers within the group;
• The sharing of similar experiences with other people;
• An elevated self-confidence; and
• An improved sense of belonging.

More recently, a Cochrane review by Woods et al. (2018) reported that RT showed “some positive effects on people with dementia in the domains of QoL, cognition, communication and mood.” Enhanced self-esteem and improved socialisation capacity from RT has been reported by Liu et al. (2021).

Of particular note was research showing the positive impact of music and photographs in mild-to-moderate Alzheimer’s disease patients. They showed improvements in depression, QoL, social functioning and reduced behavioural and psychological symptoms of dementia (BPSD). (Cuevas et al., 2020)

These improvements may be due to improved brain blood flow, notably in the frontal lobe (Tanaka et al., 2007), which is responsible for “high-order cognitive abilities such as working memory, inhibitory control, cognitive flexibility, planning, reasoning, and problem solving.” (Cristofori et al., 2019)

Importantly, RT has also been shown to provide some positive benefits “on well-being, self-esteem, daily functioning and caregiver burden”. (Yan et al. 2023)

Barriers to implementation and how barriers are addressed and overcome.

A major barrier to implementation of RT is a lack of consistency in therapy presentation, duration of therapy, training and supervision of facilitators, academic skills of facilitators, as well as feedback to presenting staff.    (Macleod et al., 2021) Poor planning time, a lack of appropriate management support, and poor staff motivation are also barriers. (Van Bogaert et al., 2016)

To remediate this problem, a standardised training program is recommended which is measured against objective external criteria facilitating improvements in knowledge and techniques. Importantly, there needs to be a theoretical framework that underpins the group RT program. (Macleod et al., 2021)

It is important to note that the Royal Commission into Aged Care Quality and Safety included testimonials in support of the merits of RT. (Tracey & Briggs, 2018)

Other barriers include gender and age, which can be predictors of the RT outcomes. Pot et al. (2010) reported that relatively severely depressed women show better treatment outcomes, perhaps because women are more receptive to the ‘emotional sharing’ involved in RT and that the “creative components of this preventive course may be better appreciated by females.”

Hence, facilitators need to be mindful that men and women respond differently, which suggests that a “men’s shed” approach may be more beneficial, because men and women socially interact and unveil themselves differently. (Barbagallo et al., 2023)

The degree of dementia is also a barrier to RT implementation. Residents showing severe dementia symptoms do not benefit in the domains of depression, neuropsychiatric presentations, cognitive function, independence or QoL due to “extreme shrinkage of the cerebral cortex and hippocampus … .” (Saragih et al., 2022) Hence, these patients may need to be excluded from group RT sessions as they may be more disruptive than contributory, secondary to agitation and aggression. (Müller-Spahn, 2003)

Finally, the cost of running RT sessions may be too expensive for some Residential Aged Care Facilities. To alleviate this problem, digital RT can be deployed. This approach “allows multiple users to participate in a therapy simultaneously. Moreover, digital RT offers convenience, such as for uploading personal materials and presenting individual triggers of personal memories.” (Moon & Park, 2020)