Gerontological Reminiscence Discussion

Geriatric Nursing 36 (2015) 372e380 Contents lists available at ScienceDirect Geriatric Nursing journal homepage: www.gnjournal.com Feature Article The effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults in long-term care: A systematic review Sharifah Munirah Syed Elias, MNSc, RN, BHSc(Nurs), Cert(Geront), PhD(c) a, b, *, Christine Neville, PhD, RN, FACMHN a, Theresa Scott, PhD, GCResMeth, BPsySc(Hons) a a The University of Queensland, School of Nursing, Midwifery and Social Work, QLD 4072, Australia Department of Special Care Nursing, Faculty (Kulliyyah) of Nursing, International Islamic University Malaysia, Jalan Hospital, 25100 Kuantan, Pahang, Malaysia b a r t i c l e i n f o a b s t r a c t Article history: Received 5 March 2015 Received in revised form 12 May 2015 Accepted 18 May 2015 Available online 19 June 2015 Loneliness, anxiety and depression are common problems for older adults in long-term care. Reminiscence therapy is a non-pharmacological intervention that may be of some benefit. In comparison to individual reminiscence therapy, group reminiscence therapy is a preferred option when dealing with the resource constraints of long-term care. The aim of this paper was to systematically review the literature in order to explore the effectiveness of group reminiscence therapy for older adults with loneliness, anxiety and depression in long-term care. Results indicated that group reminiscence therapy is an effective treatment for depression in older adults, however to date, there is limited research support for its effectiveness to treat loneliness and anxiety. Further research and an improvement in methodological quality, such as using qualitative and mixed methods approaches, is recommended to help establish an evidence base and provide better understanding of the effectiveness of group reminiscence therapy. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Anxiety Aged Depression Loneliness Nursing research Psychotherapy Reminiscence therapy Introduction In many countries, long-term care (LTC) for older adults who have poor physical and/or mental health and functional disabilities is a common part of the aged care system. For example, a broad range of recent estimates of older adults in long-term care are: Australia 5.3%1; Malaysia, 0.08%2; United States of America, 3.9%3; United Kingdom, 4.1%4; Germany, 3.2%.5 Although these percentages indicate only a small proportion of the population, the level of disability and the type of care required is significant and this will become a larger issue over the coming decades as the world population of older adults increases disproportionally to other age groups.6 The move into LTC can be very stressful for an older adult and debilitating feelings of loneliness, anxiety and depression is a significant feature.7 These feelings can last up to four years after admission to LTC.8 Other problems identified by older adults when relocating to LTC include difficulty in establishing meaningful Funding: IIUM/202/C/1/1/5377. * Corresponding author. Tel.: þ61 431470474. E-mail address: sharifah.syedelias@uq.net.au (S.M. Syed Elias). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.05.004 interpersonal relationships with other residents and staff,9e11 loss of identity and purpose in life,12 sadness and boredom13 and lack of social support. Columbus State Community College Gerontological Reminiscence Discussion

14 The prevalence rate of loneliness in LTC older adults has been reported as high as 56%15; prevalence rate for anxiety as 14%15 and prevalence rate for depression as 71.8%.16 Loneliness can be defined as the loss of valued interpersonal relationships or inability to establish satisfying relationships.17 Loneliness is a risk factor for physical and psychological health deficiencies such as dementia,18 depression,19,20 anxiety20 and cardiovascular diseases.18 Anxiety can be defined as “an anxiety and worry about several real-life problems, occurring for at least six months”.21 Anxiety is often an unrecognized comorbidity of depression.22 Depression is defined as depressed mood or loss of interest in activities of daily living for more than two weeks that can be diagnosed based on several symptoms such as depressed mood, decline in interest and pleasure and weight loss or weight gain.21 Both depression and anxiety are undertreated in older adults.23e26 The symptoms of anxiety and depression are difficult to diagnose due to coexistence with physical problems and the misbelief that these conditions are a part of the normal aging process.24 Undertreated depression and anxiety S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 can lead to low quality of life, other more serious diseases and a shorter life span.27 Suicide is also a risk for older adults with depression.28 Several approaches such as pharmacological and nonpharmacological strategies can be used to treat or prevent loneliness, anxiety and depression. Loneliness is not a condition amenable to drug treatment but can be treated through psychosocial measures such as group therapy. Pharmacological treatment such as psychotropic drugs is usually the first option to treat depression and anxiety. Common psychotropic drugs in use are antidepressants, anxiolytics, hypnotics and antipsychotics. The excessive or moderate use of psychotropic drugs can lead to insomnia, depression, falls, hyponatremia, fracture and epilepsy.29,30 Due to the adverse effects of psychotropic drugs, it is prudent to use non-pharmacological treatments such as health education, counseling and psychotherapies as the first option. Reminiscence therapy is one type of psychotherapy that could alleviate feelings of loneliness, anxiety and depression among older adults. Reminiscence by definition is a method or technique to recall past memories.31 Therapy itself can be defined as the branch of medicine that deals with different methods of treatment and healing in the cure of disease.32 Reminiscence therapy can be defined as uses the recall of past events, feelings and thoughts to facilitate pleasure, better quality of life and better adjustment to present circumstances.33 Reminiscence therapy can be structured or unstructured, and conducted in a group or individual34 setting. Reminiscence is known as reminiscence therapy when it involves communication between two or more individuals and the achievement of certain goals based on individuals needs. Gerontological Reminiscence Discussion.  Reminiscence therapy is different from simple reminiscence whereby certain elements should be considered, such as: where the therapy takes place, the aims of the therapy, the theory that may underpin the therapy, the types of participants involved, and the qualifications of facilitators.35 It is stated that there were important elements that differentiate reminiscence from other therapies.36 In reminiscence therapy, the participants are free to discuss their life stories and they can focus on both pleasant and sad memories.36 At the same time, participants can learn something from their past problems to shape their present life.37 The value of reminiscence therapy above and beyond other therapies is that it may help older people gain their personal value38 and self-identity39 by recalling past memories. Given today’s challenges in LTC, this therapy is valuable because it can be conducted during normal activities of daily life in LTC, such as during mealtime and walking around the facility LTC.Columbus State Community College Gerontological Reminiscence Discussion

38 Furthermore, staff in LTC reported that reminiscence therapy enhanced their interaction with residents, increased work satisfaction, and developed their understanding of the residents.39 Three types of reminiscence therapy are identified in the literature, simple reminiscence, life review and life review therapy.31,35 Simple reminiscence is defined as unstructured spontaneous reminiscence with the goals to increase social well-being of older people.31,35 In comparison to simple reminiscence, life review more structured and focused on both positive and negative life events. Life review therapy, is an advanced type of reminiscence therapy, which is a more formal and in-depth intervention.40 Life review therapy is conducted when dealing with a particular problem34 and can be psychotherapeutic for people who are severely depressed or anxious.31,35 Eight functions of reminiscence therapy were identified.41 Briefly, these were 1) Identity e appreciating oneself; 2) Problem Solving e recognizing one’s own strengths in dealing with problems; 3) Death Preparation e facilitating acceptance of death; 4) Teach/Inform e sharing life stories with intent to teach; 5) Conversation e developing ways of communication with other people; 6) Bitterness Revival e revisiting memories of difficult life events; 7) 373 Boredom Reduction e reminiscing to relieve feelings of boredom; and 8) Intimacy Maintenance e remembering significant people. It was found that the eight functions of reminiscence therapy41 could be grouped according to three higher order dimensions linked to well-being: positive self-functions, negative self-functions, and prosocial functions.42 Positive self-functions referred to preserving or developing self-awareness and included reminiscence for Identity, Problem Solving, and Death Preparation. Negative self-functions related to regrets about the past and rumination and included Bitterness Revival, Boredom Reduction and Intimacy Maintenance. Pro-social functions of reminiscence fostered relatedness with others such as Conversation and Teach/Inform. These functions of reminiscence therapy have relevance to older adults with depression, loneliness and anxiety. For example, Bitterness Revival, Boredom Reduction and Intimacy Maintenance functions may enhance well-being for older adults with depression. Problem Solving, Death Preparation, and Teach/Inform may be appropriate for older adults with anxiety. Gerontological Reminiscence Discussion. Identity, Problem Solving, Teach/ Inform, Conversation, Boredom Reduction, and Intimacy Maintenance functions may be applicable to older adults who are lonely. There are different types of reminiscence therapy such as transmissive reminiscence, integrative reminiscence, instrumental reminiscence and spiritual reminiscence. Transmissive reminiscence is defined as sharing past life events from one generation to the next generation.43 Integrative reminiscence therapy focuses on reviewing past events irrespective of whether these were negative or positive experiences. The aim of integrative reminiscence is to develop positive self-esteem and links between past and current memories, as well as energizing negative memories.44 Instrumental reminiscence therapy examines how past events have been resolved to enhance self-esteem.45 Finally, spiritual reminiscence therapy is defined as life review that involves people trying to find the meaning of their life and their future hopes.46 Some therapists prefer to use individual reminiscence therapy47,48 but there is evidence to support the effectiveness of group reminiscence therapy. Group reminiscence therapy usually comprises six to ten participants in each therapy session to enhance group dynamics, whereas individual reminiscence therapy is conducted on a one to one basis.49 Columbus State Community College Gerontological Reminiscence Discussion

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When comparing group reminiscence therapy to individual reminiscence therapy use in LTC, at least three authors preferred group reminiscence therapy since it encouraged social contact between the residents, enhanced communication skills, and established new relationships.11,40,50 Furthermore, a systematic review of reminiscence therapy for the treatment of depression established that the social role function of group reminiscence therapy was the defining factor that made it more effective than individual reminiscence therapy.51 From a financial appraisal, group reminiscence therapy was more costeffective than individual reminiscence therapy.40 The present systematic review expands previous work51 by including loneliness and anxiety as well as depression. It was found that loneliness could be a risk factor for anxiety20 as well as depression.19Anxiety is a common comorbid condition with depression; nevertheless many individuals may have anxiety without depression.52 To differentiate between anxiety and depression is a challenging task due to the similarity in the presentation of symptoms of depression and anxiety.23,25 Therefore, it is worthwhile to look at these three outcomes together as they are interrelated conditions often experienced by residents of LTC.7,53 The use of group reminiscence therapy in LTC is also of interest. The research question guiding this review is: ‘what is the effect of group reminiscence therapy on reducing feelings of loneliness, anxiety and depression, in older people diagnosed with symptoms of loneliness, anxiety and depression residing in long-term care settings?’54 374 S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 Articles identified through database searching Medline= 127 Embase= 157 Cinahl=61 PsycInfo= 58 Cochrane=2 Scopus=136 Sciencedirect=270 Grey literature=2710 Total (n)=3521 Articles after duplicates removed n=3146 Articles screened n=375 Articles excluded n=354 Full-text articles assessed for eligibility n=21 Full-text articles excluded, with reasons n=14 7 articles were found +1 additional article was identified by searching the reference lists of eligible articles Articles included in the analysis (n=8) Fig. 1. Modified PRISMA flow diagram of article screening and selection. The figure provides an overview of the PRISMA strategy used to identify articles that met the inclusion criteria. In total, eight studies met the inclusion criteria for this review.Gerontological Reminiscence Discussion.  Methods The Joanna Briggs Institute’s (JBI) method for a comprehensive systematic review was used to guide the study.55 Inclusion criteria This review included experimental, non-experimental, observational and qualitative studies. Systematic reviews were excluded. The population of interest was people aged 60 years and over. LTC encompassed nursing homes, assisted living facilities and residential aged care facilities. The intervention was group reminiscence therapy. Studies that used individual reminiscence therapy were excluded. The outcomes of interest were loneliness, anxiety and depression. Search strategy Both peer reviewed literature and grey literature were included in the search. The databases included in the search were Medline, Embase, Cinahl, PsychInfo, Cochrane, Scopus and Science direct. Grey literature, such as Google scholar and Proquest databases were searched for dissertations and theses. Hand searches of reference lists of studies were conducted to ensure all relevant studies were retrieved. Studies published in English and Malay languages between 2002 and 2014 and full text articles were considered for inclusion in this review. Keywords with Boolean operators that were searched in each database included: (reminiscence) OR (reminiscence therapy) OR (psychotherapy) AND (loneliness) AND (anxiety) AND (depression) OR (depressive symptoms) AND (older people) OR (older adults) OR (elderly). Gerontological Reminiscence Discussion

#The literature search strategy identified 3521 potentially relevant studies (Fig. 1). Fig. 1 provides an overview of the PRISMA strategy used to identify articles that met the inclusion criteria.56 Initially, 3146 duplicates studies were excluded; resulting in 375 articles screened for inclusion in this review. A further 354 studies were removed based on the title and abstract. The remaining 21 articles were assessed for inclusion in this review. Fourteen articles were excluded for the following reasons: individual reminiscence therapy; for older adults with dementia; community and hospital/ clinics setting; participants aged below 60 years, and published in languages other than English and Malay language. The reference lists of the seven articles that met the inclusion criteria for this review were searched for additional relevant articles. This literature search method identified one further article that met the inclusion criteria. In total, eight studies met the inclusion criteria for this review. These eight studies were assessed for methodological quality, and further data extraction and synthesis. Assessment of methodological quality The eight studies were quantitative studies. All studies were critically appraised using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 Statistics Assessment and Review Instrument (JBI-MAStARI).55 Three independent reviewers performed the methodological validity assessments. The reviewers then met and discussed any disparity of the assessments to reach a final conclusion. Results from the assessments of methodological quality supported the inclusion of all eight studies in the review (Table 1). Since none of the eight studies met all 10 of the JBI MAtSARI criteria e especially concerning the treatment groups and experimental design e a decision criteria cut-off of five, out of a possible 10 points was agreed among the reviewers. Data collection and extraction The data were collected and extracted from the studies using the standardized data extraction tool from JBI-MAStARI.55 The first author performed data extraction while the second author checked the data that were extracted. Gerontological Reminiscence Discussion. The data extracted included specific details about the methodology, settings, participants, interventions, duration, outcome measures and findings. Data synthesis Due to heterogeneity of the results such as different methodological approaches, different findings and a limited number of studies for loneliness and anxiety outcomes, it was not possible to conduct meta-analysis of these three outcomes. Therefore, the results were presented in narrative form, including tables to clarify these. Gerontological Reminiscence Discussion. Results A summary of study characteristics is presented in Table 2. Only one study examining an outcome of loneliness was found.57 Two studies examining anxiety58,59 and eight studies examining depression34,43,57e62 were identified. Three studies measured more than one outcome.57e59 Of the eight studies, three studies were from the United States of America (USA),34,43,58 three studies were from Taiwan,57,61,62 one study from the United Kingdom (UK),59 and one study from Iran.60 None of the eight studies employed a randomized controlled trial (RCT) design. These involved small sample size, i.e., fewer than 100 participants. Two studies involved males only,57,61 one study involved females only34 and five studies involved both males and females.43,58e60,62 All of the studies used a control group, the interventions were between four and twelve weeks’ duration. In relation to the outcome of loneliness, the single study was conducted in Taiwan with 92 participants (45 participants in the reminiscence group and 47 participants in the control group). The 375 therapy was conducted over an eight weeks period. The scale measuring loneliness was the Revised University of California Los Angeles loneliness scale (RULS-V3).63 The finding was a significant positive short-term effect (3 months follow-up) of reminiscence therapy to combat loneliness. In regard to the outcome of anxiety, two studies were found. These studies were conducted in the USA and the UK. Both of these studies were quasi-experimental. Sample size differed; 35 participants58 and 73 participants.59 These studies implemented different elements in reminiscence therapy. One study explored reminiscence therapy and spiritual reminiscence therapy58 whereas another study investigated group reminiscence therapy and individual reminiscence therapy.59 Although both measured anxiety, they used different scales.58,59 Emery (2002) used the State-Trait Anxiety Inventory (STAI)64 and Haslam et al (2010) used the Hospital Anxiety and D … Gerontological Reminiscence Discussion