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
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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).
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
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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
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
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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
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
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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,
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
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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
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
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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.
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)
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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).
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.
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A visual display of the number of communicative turns for each session are shown in Figure 3.
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
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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
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
15

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
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,
16

communicative interactions and engagement in this adult population.
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
17

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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