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Geriatric Nursing 36 (2015) 372e380

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Geriatric Nursing

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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 b Department of Special Care Nursing, Faculty (Kulliyyah) of Nursing, International Islamic University Malaysia, Jalan Hospital, 25100 Kuantan, Pahang, Malaysia

a r t i c l e i n f o

Article history: Received 5 March 2015 Received in revised form 12 May 2015 Accepted 18 May 2015 Available online 19 June 2015

Keywords: Anxiety Aged Depression Loneliness Nursing research Psychotherapy Reminiscence therapy

Funding: IIUM/202/C/1/1/5377. * Corresponding author. Tel.: þ61 431470474.

E-mail address: sharifah.syedelias@uq.net.au (S.M

0197-4572/$ e see front matter � 2015 Elsevier Inc. http://dx.doi.org/10.1016/j.gerinurse.2015.05.004

a b s t r a c t

Loneliness, anxiety and depression are common problems for older adults in long-term care. Reminis- cence 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 methodo- logical 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.

� 2015 Elsevier Inc. All rights reserved.

Introduction

In manycountries,long-term care(LTC) forolderadults whohave 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 indi- cate 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 sig- nificant 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

. Syed Elias).

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interpersonal relationships with other residents and staff,9e11 loss of identity and purpose in life,12 sadness and boredom13 and lack of social support.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 plea- sure 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 phys- ical 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 373

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 non- pharmacological strategies can be used to treat or prevent loneli- ness, anxiety and depression. Loneliness is not a condition amenable to drug treatment but can be treated through psycho- social 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 epi- lepsy.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. Remi- niscence 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 qualifica- tions 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.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 liter- ature, 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 prob- lems; 3) Death Preparation e facilitating acceptance of death; 4) Teach/Inform e sharing life stories with intent to teach; 5) Con- versation e developing ways of communication with other people; 6) Bitterness Revival e revisiting memories of difficult life events; 7)

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 pro- social 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 depres- sion, 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. Identity, Problem Solving, Teach/ Inform, Conversation, Boredom Reduction, and Intimacy Mainte- nance 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 reminis- cence 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 ther- apy47,48 but there is evidence to support the effectiveness of group reminiscence therapy. Group reminiscence therapy usually com- prises six to ten participants in each therapy session to enhance group dynamics, whereas individual reminiscence therapy is con- ducted on a one to one basis.49 When comparing group reminis- cence 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 cost- effective 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 pre- sentation 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

Articles after duplicates removed n=3146

Full-text articles assessed for eligibility

n=21

7 articles were found +1 additional article was identified by searching

the reference lists of eligible articles

Articles included in the analysis (n=8)

Articles screened n=375

Articles excluded n=354

Full-text articles excluded, with reasons

n=14

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

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.

S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380374

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, obser- vational 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 resi- dential aged care facilities. The intervention was group reminis- cence 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: (remi- niscence) OR (reminiscence therapy) OR (psychotherapy) AND (loneliness) AND (anxiety) AND (depression) OR (depressive symptoms) AND (older people) OR (older adults) OR (elderly).

The literature search strategy identified 3521 potentially rele- vant 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 in- struments from the Joanna Briggs Institute Meta-Analysis of

S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 375

Statistics Assessment and Review Instrument (JBI-MAStARI).55

Three independent reviewers performed the methodological val- idity 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 in- clusion 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. The data extracted included specific details about the methodology, settings, participants, in- terventions, duration, outcome measures and findings.

Data synthesis

Due to heterogeneity of the results such as different methodo- logical 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 re- sults were presented in narrative form, including tables to clarify these.

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 ran- domized 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

Table 1 Assessment of methodological quality of group reminiscence studies using JBI MAtSARI.

Criteria Chiang et al (2010)

1. Was the assignment to treatment groups truly random? U 2. Were participants blinded to treatment allocation? U 3. Was allocation to treatment groups concealed from the allocator? N 4. Were the outcomes of people who withdrew described and

included in the analysis? Y

5. Were those assessing outcomes blind to the treatment allocation? U 6. Were the control and treatment groups comparable at entry? Y 7. Were groups treated identically other than for the named interventions? Y 8. Were outcomes measured in the same way for all groups? Y 9. Were outcomes measured in a reliable way? Y 10. Was appropriate statistical analysis used? Y

Y ¼ Yes, N ¼ No, U ¼ unclear, NA ¼ not applicable.

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 partici- pants58 and 73 participants.59 These studies implemented different elements in reminiscence therapy. One study explored reminis- cence therapy and spiritual reminiscence therapy58 whereas another study investigated group reminiscence therapy and indi- vidual 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 Hos- pital Anxiety and Depression Scale (HADS).65 A significant result was found by one study e group reminiscence, individual remi- niscence and group control activity were effective in alleviating anxiety.59 However, post hoc analysis discovered the group control activity produced significant improvements in well-being mea- sures as compared to the other two groups. By contrast, another study found that spiritual reminiscence therapy was not signifi- cantly effective in reducing anxiety.58

In relation to the outcome of depression, all eight studies were quasi-experimental. One study was conducted in a specialized care unit for older adults,59 two studies were conducted in assisted living facilities34,58 and five studies were conducted in nursing homes.43,57,60e62 The number of participants involved in the reminiscence therapy groups ranged from 21 to 73. Three studies compared the different types of reminiscence therapy for older adults with depression. One study compared reminiscence therapy and spiritual reminiscence therapy.58 The other two studies compared; (1) integrative reminiscence and instrumental remi- niscence60 (2) reminiscence and transmissive reminiscence.43 Four studies compared group reminiscence to a control group.34,57,61,62

One study explored the effectiveness of group reminiscence compared to individual reminiscence and a control group.59 Five of the eight studies found that reminiscence therapy was markedly effective in reducing depression.43,57,59,60,62 However, three studies revealed non-significant findings regarding the effects of reminis- cence therapy on depression.34,58,61

With regard to the content or topics of discussion included in the group reminiscence therapy studies, five57e60,62 provided full information, one study provided some information of the therapy contents61 and another two studies reported no information about the topics discussed34,43 (Table 3). One study62 replicated topics from a previous study57 with modification. Facilitators were experienced in conducting reminiscence therapy or had received

Emery (2002)

Haslam et al (2010)

Wilson (2006)

Karimi et al (2010)

Stinson and Kirk (2006)

Chao et al (2006)

Chueh and Chang (2014)

N Y NA Y Y N Y NA Y NA U U U U N N U U U U U N N NA U N N Y

U N N Y U N U Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Table 2 Summary of studies about group reminiscence therapy for older adults with loneliness, anxiety and depression residing in long-term care.

Author/Year/Country Design Setting/No. of sites

Sample size (n)

Interventions (n) Duration (weeks)/ session

Outcome measures

Findings

Studies of loneliness and depression Chiang et al/2010/

Taiwan Quasi-experimental study

Nursing home/1 92 males Reminiscence: 45 Control: 47

8/weekly RULS-V3 A significant positive short-term effect (3 months follow- up) of reminiscence to loneliness, as compared to those in the comparison group was found. (p < 0.0001)

CES-D Significant positive short-term effect of reminiscence to comparison group (p < 0.0001)

Studies of anxiety and depression Emery/2002/USA Quasi-experimental

study Assisted living facility/2

35 males & females

Conventional reminiscence: 10 Spiritual reminiscence: 14 Wait-list (no intervention): 11

8/weekly STAI GDS (15 items)

Spiritual reminiscence therapy did not significantly decrease anxiety (F(1.76, 1) ¼ 0.07, p ¼ 0.20) and depression (F(0.06, 1) ¼ 0.00. p ¼ 0.81)

Haslam et al/2010/UK Quasi-experimental study

Standard or specialized care unit/7

14 males 59 females

Group reminiscence: 41 Individual reminiscence: 34 Group control activity (skittles): 40

6/weekly HADS Significant effect of group reminiscence, individual reminiscence and group control activity on well-being measures (F(2, 71) ¼ 3.36, p ¼ 0.04).

Studies of depression Wilson/2006/USA Quasi-experimental

study Nursing homes/2 45 males &

females Reminiscence: 15 Transmissive: 15 reminiscence Control: 15

12/weekly GDS (30 items) Both treatment groups evidenced lower scores on the GDS after the intervention period (F(2, 41) ¼ 70.46, p ¼ 0.00). The difference between the efficacy of the reminiscence group and that of the transmissive reminiscence group was not statistically significant, but both were effective in decreasing depression scores.

Karimi/2010/Iran Quasi-experimental study

Nursing home/1 12 males 17 females

Integrative reminiscence group: 10 Instrumental reminiscence: 9 group Social discussion group: 10

6/weekly GDS (15 items) Integrative and instrumental reminiscence differed significantly (F(27.095), p < 0.01). Integrative reminiscence showed statistically significant reduction in symptoms of depression compared to the control group. Although instrumental reminiscence therapy also reduced depressive symptoms, this improvement was not statistically significant compared to the control group.

Stinson & Kirk/2006/ USA

Quasi-experimental study

Assisted living facility/1

24 females Reminiscence group: 12 Activity (control) group: 12

6/twice weekly GDS (30 items) No significant difference between reminiscence and control groups (F(1.31), p ¼ 0.27). A non-significant decrease in depression in the reminiscence group at the completion of six weeks, indicating a trend toward a positive result with reminiscence group sessions.

Chao et al/2006/ Taiwan

Quasi-experimental study

Nursing home/1 18 males 6 females

Reminiscence group: 12 Control group: 12

9/weekly GDS-S Group reminiscence therapy for depression was not significant (p ¼ 0.339)

Chueh & Chang/2014/ Taiwan

Quasi-experimental study

Nursing home/1 21 males Reminiscence: 11 Control group (routine care): 10

4/twice weekly TGDS Group reminiscence therapy can effectively reduce depression for a 6-month period (p ¼ 0.013)

RULS-V3 ¼ Revised University of California Los Angeles loneliness scale63; STAI ¼ State-Trait Anxiety Inventory64; HADS ¼ Hospital Anxiety and Depression Scale65; GDS 15 items ¼ Geriatric Depression Scale66; CES-D ¼ Center for Epidemiological Studies Depression Scale67; GDS 30 items ¼ Geriatric Depression Scale68; GDS-S ¼ Chinese version of the GDS-S (Geriatric Depressive Scale-Short Edition)69; TGDS ¼ The Taiwan Geriatric Depression Scale.70

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Table 3 Group reminiscence protocol for each study.

Author Topics included in group reminiscence therapy Facilitator

Chiang et al (2010) Topics included in 8 weeks of therapy: (1) self-introduction and sharing of past life events; (2) Increasing consciousness of feelings and assisting participants to discuss their feelings; (3) Recognizing any positive relationships from past memories and the ways to integrate good aspects of past relationships to current relationships; (4) Remembering family and personal life memories; (5) Shifting of life; (6) Recognizing personal achievements and finding personal aims; (7) Emphasizing personal aims and strengths; and (8) Reviewing of all sessions and conclusion.

Two facilitators who were master students with experience working with older people and group reminiscence therapy.

Emery (2002) Topics included in 8 weeks of therapy: (1) “Firsts” such as stories of first baby and first time driving; (2) School days; (3) Life work; (4) Customs; (5) Battles won and lost, such as memories during World War II, and battles with their addiction; (6) Critical moments in life; (7) Past and present and (8) Inspirational words

Two facilitators involved who were clinicians and had received training on group reminiscence therapy.

Haslam et al (2010) Topics included in 6 weeks therapy; (1) Childhood memories; (2) School time memories; (3) Home life; (4) Marriages; (5) Personal life; and (6) Vacations.

Three facilitators had completed training in reminiscence and had experience conducting group activities.

Wilson (2006) Information not available. One facilitator conducted group reminiscence therapy to reduce experimental bias.

Karimi et al (2010) Topics included in 6 weeks of therapy: (1) Personal history: (2) Life achievements: (3) Critical moments in life: (4) History of good and bad things: (5) History of distress or grief and (6) The purpose of life and faith. Participants were also given the topic prior to the next session to prepare the memories that they wanted to share with group members.

A facilitator holding a master degree conducted the group reminiscence therapy and was supervised by a registered clinical psychologist.

Stinson & Kirk (2006) Information not available. Information not available. Chao et al (2006) Topics included in 9 weeks of therapy: (examples only provided) childhood history;

history of home/family; and significant memories in their life. A facilitator with college-level qualifications in psychiatric nursing led the group reminiscence therapy with the assistance of a head nurse.

Chueh & Chang (2014) Topics included in 4 weeks (two sessions per week) that was modified from Chiang et al (2010); (1) Self introduction and life moments in relation to wars; (2) The importance of sharing their feelings; (3) Recognizing past meaningful relationships and how to integrate the positive components of past relationships to present relationships; (4) Remembering past personal events; (5) Remembering problems related to life transitions; (6) Recognizing personal achievements and personal aims; (7) Recognizing own strengths and (8) Conclusion of eight sessions.

One described only as very experienced facilitator in group reminiscence therapy led the sessions.

S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 377

training on group reminiscence therapy. However, one study did not provide information about the facilitator of the group remi- niscence therapy.34 Four studies involved one facilitator,43,60e62

two studies involved two facilitators57,58 and one study involved three facilitators.59

Discussion

Quality of the studies

The assessment of methodological quality revealed that three of the eight studies met the minimum score of five out of the ten criteria. No study included the important step of concealment of allocation to treatment groups by the allocator e i.e., criteria 3. However the included studies were quasi-experimental studies. The studies fulfilled similar criteria in the methodological quality assessment checklist. For example, all eight studies had comparable groups, identical treatment except for the treatment group, parallel outcome measurements across all groups, reliable outcome mea- surements and correct use of statistical tests.

Another important issue was the implementation of a control condition. Five out of eight studies implemented waiting list con- trol groups.43,57,58,61,62 Another three studies applied attention control activities such as skittles and social interaction.34,59,60 It is important to evaluate the control group since some studies implementing a waiting list control group produced significant results. As identified in one study, group reminiscence therapy was effective in reducing depression for a six-month period compared to routine care.62 However this result must interpreted with consideration given to the lack of equivalence of social interaction in the comparison condition. That is, it is not possible to rule out whether social interaction with other group members may have been the mechanism for change in the group reminiscence

condition compared to the usual care condition. Therefore, it is suggested that in future research the control group should ideally be an attention-controlled condition to address this limitation.

The variability in outcomes could be attributed to a number of methodological components such as dropout rates, follow-up time after the implementation of the interventions, and content of the therapy. Most of the studies reported the dropout rate and follow- up time after implementation of the intervention. One study reported high attrition (31%), which did not appear to influence the results as the findings showed reminiscence therapy was signifi- cantly effective for older adults with loneliness and depression.57

The reasons for high attrition, reported by the majority of the studies, included hospitalization, death, and attending health appointments. In terms of reminiscence therapy content, six out of eight studies detailed the specific content of the ther- apy/sessions.57e62 Although reminiscence therapy content differed between the studies, each covered three important phases; self- introduction, topics of discussion, and conclusion.

Clinical effects of group reminiscence therapy

This paper reviewed eight studies that examined the effective- ness of group reminiscence therapy on loneliness, anxiety, and depression in older adults in LTC. Only one study investigated group reminiscence therapy and loneliness.57 Despite the significant findings, it is difficult to make a conclusion regarding the clinical effects of group reminiscence for loneliness from this one study. Additionally, the control group was a waiting list control condition that did not include an equivalent activity. This study also involved only males therefore limiting the ability to generalize the findings to females. Therefore there is limited evidence to conclude that reminiscence therapy is effective in decreasing or eliminating feelings of loneliness for older people in LTC.

S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380378

The evidence for the effectiveness of reminiscence therapy to treat anxiety was also limited due, in part, to the variability of methods used in the included studies. Various types of in- terventions (conventional versus spiritual reminiscence and group reminiscence versus individual reminiscence), various settings (assisted living facilities and specialized care unit), duration of the interventions (eight weeks and six weeks) and different outcome measures (STAI and HADS) make it difficult to sum up the effec- tiveness of the therapy. More rigorous research in this field is crucially needed.

The findings related to depression varied across the included studies. Although numerous scales were used to measure depres- sion, the Geriatric Depression Scale (GDS)66 was the most frequently chosen. Differing versions of GDS were used, three of six studies reported significant results.43,60,62 Another three studies reported non-significant results.34,58,61 Non-significant results may have resulted from the small sample sizes, which were less than 35 participants. Two other studies that used different scales, HADS and the Center for Epidemiological Studies Depression scale (CES-D) also reported significant results.57,59 Both of these studies were quasi-experimental and involved larger sample sizes e 92 partici- pants57 and 73 participants.59 Due to heterogeneity of the results, it was not possible to conduct a meta-analysis of the studies examining the outcome of depression. Yet, the available evidence indicated that group reminiscence therapy could support older adults who are depressed. Furthermore, it was found that social interaction between people in the group reminiscence therapy increased and this finding has relevance to older adults living in LTC.59

Theoretical framework

Out of eight studies, only two studies used a theoretical framework. One study used social identity theory to guide their study.59 From this framework, it was predicted that group remi- niscence therapy would provide better outcomes as compared to individual reminiscence. Their study categorized the outcomes into cognitive improvement and enhanced well-being.59 The results revealed that group reminiscence therapy, individual reminiscence therapy and group control activities produced significant effects on well-being measures of depression, anxiety, life improvement and quality of life pre-to post-intervention. However, further between- groups analysis showed that only the group control activity produced significant improvements in well-being compared to group reminiscence and individual reminiscence. The usefulness of social identity theory was clear in this study since the group control activity that encouraged more social activities reduced feelings of anxiety and depression for participants.

Another study used a framework called the Lin framework.34

This framework includes five stages; antecedent, individual assessment, establishing the therapeutic purposes, choosing a suitable reminiscence therapy modality, and outcome measure- ments. However, their study did not critically discuss the integra- tion of the Lin framework into their study.34

Types of reminiscence therapy

From this systematic review, several types of reminiscence therapy have been identified. These are transmissive reminiscence therapy,43 integrative reminiscence therapy,60 instrumental remi- niscence therapy60 and spiritual reminiscence therapy.58 In this review only integrative reminiscence therapy was found to be significantly effective in reducing depression among older adults in LTC.60 Although the use of transmissive and instrumental remi- niscence led to a reduction on depression scores, these were not at

a statistically significant level. Therefore, despite the modest find- ings it is clear that there is a great deal of scope for further study on transmissive reminiscence, instrumental reminiscence and spiri- tual reminiscence therapy.

Generally, several limitations of group reminiscence therapy were identified in this review, such as small sample size, attrition rates that may have influenced the findings, insufficient evidence for the long-term effects of the therapy, lack of social interaction in control conditions, and varying content of group reminiscence therapy. Special training for staff in LTC in group reminiscence therapy is important prior to conducting it, and may require monetary support from the institution, although conducting the therapy itself is cost-beneficial.71,72

Recommendations

Only a few studies identified the benefits of group reminiscence therapy for loneliness, anxiety and depression in older adults in LTC. Moreover, all studies in this review were quantitative studies. Thus, diverse research designs were needed for a clearer under- standing of group reminiscence therapy as a whole. That is, quali- tative studies and mixed-method studies might provide different views of the effectiveness of group reminiscence therapy. Qualita- tive work might be beneficial to provide a better understanding from the older adults’ perspective regarding group reminiscence therapy, such as their experiences after group reminiscence ther- apy. Further studies from different cultural groups could enhance this body of knowledge. It has been suggested that different methodologies, including a combination of experimental studies and qualitative research could provide a better understanding of the effects of reminiscence therapy.73,74 Furthermore since different types of reminiscence therapy had been examined in the studies included in this review e spiritual, transmissive, integrative and instrumental reminiscence therapies e which resulted in inconsistent outcomes, further exploration of the effects of different types of reminiscence therapy are recommended.

Although several studies have been conducted on the effec- tiveness of group reminiscence therapy for older adults who are lonely, depressed and anxious, no firm conclusions can be made from the results. This is due to the differing implementation stra- tegies for the intervention, therapy durations and scales used to evaluate the effectiveness of the therapy. Thus, a standardized protocol for reminiscence therapy, such as topics to be covered and uniform duration, is needed for implementation across the populations.

Conclusion

The majority of group reminiscence therapy studies reviewed were quasi-experimental and included small participant samples, therefore there are no conclusive findings to be made. Notwith- standing the lack of empirical evidence, as there are no reported adverse events to reminiscence therapy, and it can be practically implemented in long-term care settings, it should certainly be considered a worthwhile treatment.

Acknowledgments

The first author would like to acknowledge the Malaysian Ministry of Education and International Islamic University Malaysia for the scholarship support.

S.M. Syed Elias et al. / Geriatric Nursing 36 (2015) 372e380 379

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